Open access peer-reviewed chapter

Prevention and Management of Complications from Esophagectomy

Written By

Jacqueline Oxenberg

Submitted: 19 February 2018 Reviewed: 16 May 2018 Published: 05 November 2018

DOI: 10.5772/intechopen.78757

From the Edited Volume

Esophageal Cancer and Beyond

Edited by Jianyuan Chai

Chapter metrics overview

1,670 Chapter Downloads

View Full Metrics

Abstract

While surgery plays a major role in the treatment and potential cure of esophageal cancer, esophagectomy continues to have a significant amount of morbidity compared to other surgical oncology procedures. Efforts to improve morbidity and mortality from esophagectomy include the Consensus Guidelines for Complications from Esophagectomies, Enhanced Recovery after Surgery protocols as well as others. Although we strive to improve morbidity and mortality after these surgeries, adverse events still occur. They affect not only patient quality of life and increase cost of care for esophageal cancer but also have a negative impact on overall cancer survival. This chapter reviews the prevention of adverse outcomes from esophagectomies as well as discusses the management of many complications that may occur more common to the operation.

Keywords

  • esophagectomy complications
  • prevention of esophagectomy complications
  • management of esophagectomy complications

1. Introduction

Adverse events from esophagectomies directly impact patient quality of life, cancer recurrence/survival, hospital costs and resources, as well as require a great deal of energy from those managing them [1, 2]. Prevention of surgical complications is of utmost importance; however, adverse events from this major surgical procedure still occur, even in high-volume centers or experienced hands. Mortality can range from 7 to 9% while morbidity ranges from 17 to 74% [3]. Prevention, early recognition, and adequate management of complications can decrease mortality [4]. While many studies evaluate postoperative morbidity using even randomized methods, randomized studies on the management of postsurgical complications are by nature extremely limited.

Advertisement

2. Selection of the appropriate patient and surgeon

2.1. The optimal patient

Patient optimization and use of appropriate selection criteria are key to minimizing postoperative morbidity. Unfortunately, those risk factors for the development of esophageal cancer may also put patients at an increased risk for postoperative complications. Risk factors include age, elevated BMI, ECOG score/functional status, dyspnea, diabetes, chronic obstructive pulmonary disease, smoking, alkaline phosphatase level elevations, low serum albumin, and increased complexity score [5, 6, 7, 8, 9, 10, 11]. However, age and performance status continue to be the most commonly reported. Neoadjuvant treatments have not been consistently proven to be a risk factor. While fibrosis often occurs after chemoradiation, potentially making surgical resection more difficult, data showing optimal timing to surgery after neoadjuvant chemoradiation and its affect on postoperative morbidity are mixed [12].

2.2. How to optimize the patient

Malnutrition has been reported in 57–80% of patients with esophageal cancer [13, 14]. Many factors can be attributed to malnutrition prior to surgery and include patient factors, chemotherapy, radiation therapy, and tumor-related causes [15]. It is important to recognize that even obese patients can suffer from malnutrition. While laboratory values and anthropometric measurements can be useful, their values can vary and therefore may not be clinically relevant. Therefore, a weight loss of greater than 10% for 6 months or 5% for 1 month is considered malnourished [16].

For the malnourished patient, preoperative optimization of nutrition through the advice of a dietician is key, but other measures should be considered as well if a patient is unable to tolerate at least 50–75% of their caloric needs [15]. The preferred intervention should be handled in a multidisciplinary setting and be initiated as early as possible. This decreases the amount of weight loss, increases chances of completion of neoadjuvant therapies, and decreases hospital admissions [17].

Recommendations to maximize oral nutrition intake include dividing daily oral intake into five to six small meals where the patient is given enough time to eat, eating only foods with a high nutritional content, paying attention to presentation and preparation of meals to make food as desirable as possible, enriching meals and drinks and taking advantage of those days where the patient feels like eating, modifying the consistency of foods to ease swallowing, preventing fatigue, decreasing the risk of aspiration, eating non-irritating soft and smooth foods at room temperature and maintaining oral hygiene for those with mucositis [15]. Patients should also be advised to supplement meals with dietary supplements. The preoperative intake of combined “immunonutrition” products consisting of arginine, glutamine, polyunsaturated omega-3 fatty acids, nucleotides, and antioxidant micronutrients has been shown to decrease postoperative infectious complications and length of hospital stay [15, 18, 19].

For those unable to tolerate adequate nutrition, even with optimization and supplementation, other interventions are needed. These include either stent placement or percutaneous, endoscopic, or surgical placement of feeding gastrostomy or jejunostomy tubes. Esophageal stent placement has the benefit of being placed during endoscopic ultrasound, a common staging procedure. While it may improve dysphagia in the neoadjuvant setting, chest pain can occur and stent migration can be seen in up to 46% of patients [20]. although stent migration can be problematic, it is often a sign of tumor response to neoadjuvant therapy, and therefore the stent may not always need to be replaced. Other reported complications of stent placement in the neoadjuvant setting include perforation, mediastinitis, bowel perforation from migration, tracheo-esophageal fistula, and bleeding [21].

Jejunostomy and gastrostomy tube placement have been proven safe and effective for perioperative nutrition. These can be placed in the laparoscopic, open, endoscopic, or even percutaneous settings. Endoscopic placement may be difficult if a patient has a severe malignant stricture/obstruction, which is often the case when a patient is suffering from severe malnutrition and unable to pass food or liquids through the site of tumor. Gastrostomy tubes have the advantage of bolus feeding, which may improve quality of life. While gastrostomy tube placement has been proven to be safe without increasing the risk of postoperative morbidity, jejunostomy tube placement is often preferred given the stomach is the preferred organ for a neo-esophagus. Jejunostomy tubes are often placed at the time of esophagectomy as well for supportive care. However, some data support that the placement of jejunostomy tubes during esophagectomy is not always necessary [22, 23, 24]. Unfortunately, tube feeds cannot be given in boluses with jejunostomy tubes, which, if occurs, can lead to diarrhea and further dehydration. Patients therefore require an ongoing pump connection for feedings.

Smoking cessation is crucial to improving morbidity from esophagectomy. This may be most beneficial if performed greater than 90 days before surgery [25]. Active smoking has also been shown to increase recurrence rates of cancer after esophagectomy [26]. Therefore, smoking cessation counseling and supportive programs are necessary when patients are being assessed for esophagectomy.

2.3. The optimal surgeon/hospital

When deciding the optimal surgeon, it is important to understand that outcomes depend on two major factors: experience and resources. It is well known that with increasing numbers of esophagectomies performed, postoperative morbidity and mortality are improved. In addition, long-term survival can also improve [27]. While data show improved outcomes at higher volume centers, this is inconsistent and may depend further on individual surgeon volumes and hospital resources [28]. Begg et al. described low-volume hospitals as 1–5 esophagectomies/year, medium volume 6–11 esophagectomies/year, and high-volume centers as those performing >11 esophagectomies/year, with an improved mortality with increasing hospital volumes [29]. Later, Birkmeyer et al. divided hospital volumes to <2 esophagectomies/year as low-volume and high-volume centers as >19 esophagectomies/year [30]. The 2003 Leapfrog Group recommended 13 esophagectomies/year as a minimum volume standard [31]. However, esophagectomies at mid-volume centers can also be safely performed, especially with a two-surgeon approach [32]. Hospital type may also be important where improved reoperation rates and mortality are seen when surgery is performed at University centers or institutions centralizing esophageal cancer care [33, 34, 35].

Early recognition and treatment of complications appears to be just as important as prevention to improve mortality [36]. The recognition of postoperative problems improves with experience, making hospital volumes as well as surgeon volumes important. With morbidity rates being high, early intervention is of utmost importance to prevent further adverse outcomes or even death. In fact, even in low-volume hospitals, mortality may remain low if adequate resources are available [28, 37]. Therefore, these surgeries should only be performed at institutions well equipped to handle the possible complications [38, 39, 40]. Ancillary departments that should be available in the postoperative care may include gastroenterology, interventional radiology, cardiology, an astute critical care team, and others. Resources readily available and proven to improve complications also include nurse-to-patient ratios, where the incidence of pulmonary and infectious complications was shown to be increased when nurses had more than two patients [41].

2.4. Optimal surgical approach

Tumor location as well as surgeon experience often dictates the type of surgery performed. Multiple accepted operative approaches to esophageal carcinoma include Ivor Lewis esophagogastrectomy, McKeown esophagogastrectomy, transhiatal esophagogastrectomy, and left transthoracic or thoracoabdominal approaches. Minimally invasive techniques include laparoscopic and robotic esophagectomies. While minimally invasive esophagectomies have been shown to be safe and effective with equivalent oncologic outcomes, robotic, rather than laparoscopic approaches are becoming common [42, 43, 44]. However, one should be aware that there is a learning curve when a surgeon is transitioning to minimally invasive esophagectomies [45]. Transthoracic esophagectomies include the Ivor Lewis esophagogastrectomy and the McKeown esophagogastrectomy. Morbidity varies on the location of the anastomosis and if the transthoracic approach was used. While the transthoracic approach may have an increased morbidity, it does allow for extended lymphadenectomies to be performed, possibly increasing long-term survival [10, 46] .

Advertisement

3. Prevention and management of complications

The Esophagectomy Complications Consensus Group (ECCG) is a group of 21 high-volume surgeons from 14 countries that compiled a complete list of complications from esophagectomies [3]. These adverse events are separated into pulmonary, cardiac, gastrointestinal, urologic, thromboembolic, neurologic/psychiatric, infectious, wound/diaphragm, and others. They also aimed to standardize the definitions and reporting of complications since reported literature varied depending on adverse reactions and even mortality definitions. These definitions were defined for anastomotic leak, conduit necrosis, chyle leak and vocal cord injury/palsy. Given the large number of possible complications, this chapter reviews those more common or even specific to esophagectomy.

3.1. Atrial fibrillation

Atrial fibrillation can occur in over 20% of patients undergoing esophagectomy, particularly when the transthoracic approach is used [47, 48]. Its occurrence unfortunately can result in hemodynamic instability as well as put patients at an increased risk for stroke. Atrial Fibrillation may also be an early warning sign for morbidity, especially anastomotic leak [49]. The mechanism and pathophysiology of postoperative atrial fibrillation is incompletely understood, although we know predisposing factors include advanced age, coronary artery disease, heart failure, hypertension, mitral valve disease, and previous history of atrial fibrillation [50]. One randomized, controlled trial showed that the preoperative use of amiodarone via IV infusion significantly reduced the incidence of atrial fibrillation; however, no differences were seen in median hospital stay, ICU stay, or adverse events [51]. In a study evaluating amiodarone administration through the jejunostomy tube postoperatively, there was only a trend towards lower occurrence and a shorter length of stay [52]. Beta-blockers should be continued for the prevention of atrial fibrillation as well if a patient is already taking them, but may require a reduced dose for the prevention of hypotension, especially with epidural anesthesia. Calcium channel blockers, particularly diltiazem, can also be used for the prevention of atrial fibrillation and may have less effect on blood pressure than other calcium channel blockers or beta-blockers [53]. If atrial fibrillation occurs, amiodarone, calcium channel blockers, and beta-blockers are all treatments to be considered, depending on the patient’s hemodynamics.

3.2. Respiratory failure/pneumonia/prolonged ventilation

Respiratory complications in patients undergoing esophagectomy can be problematic and are often causes of mortality. When patients need to be reintubated, many require bag ventilation or positive pressure prior to intubation, which may cause insufflation of the esophagus and stomach, placing pressure on the anastomosis or staple lines. For that reason, CPAP is often avoided as well. Direct airway visualization during reintubation is also important to prevent mechanical injury in case the esophagus is intubated rather than the trachea, especially if a cervical anastomosis is performed.

Pneumonia has been shown to significantly increase mortality compared to other complications, even anastomotic leak [6, 8]. Unfortunately, it can also be the most common postoperative complication and cause for respiratory failure and prolonged ventilation [7]. The American Thoracic Society and American Infections Diseases Society define pneumonia into hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health-care-associated pneumonia (HCAP) [54]. The revised Uniform Pneumonia Score aims to define pneumonia occurring after esophagectomies and includes temperature, leukocyte count, and pulmonary radiographic findings [55]. Prevention, early recognition, and treatment as well as correction of causes are key.

Aspiration is a major cause of pneumonia. This occurs more often with a cervical anastomosis, especially with recurrent laryngeal nerve injury. Recurrent laryngeal nerve palsy can occur secondary to stretching, thermal injury, or even compression. If occurs, patients may suffer from hoarseness as well as pulmonary complications such as dyspnea and aspiration, which puts them at an increased risk for pneumonia and reintubation/prolonged ventilation. However, recurrent laryngeal nerve injury may not always present as obvious hoarseness, as we know from thyroid surgery data, and therefore its occurrence may be underreported. The ECCG defines vocal cord injury/palsy as a vocal cord dysfunction postresection where confirmation and assessment are achieved by direct examination [3]. There are three types of injuries/palsies that are each further separated into unilateral (A) and bilateral (B): Type 1 includes a transient injury requiring no therapy, where only dietary modifications are needed; Type 2 is an injury requiring elective surgical procedures such as thyroplasty or medialization procedures; Type 3 is an injury requiring acute surgical intervention due to aspiration or other respiratory issues that include thyroplasty or medialization procedures. Injury to the left recurrent laryngeal nerve is most common and is mainly associated with esophagectomies that include cervical anastomoses or dissections, McKeown-type operations. Therefore, prevention may include performing thoracic anastomoses or careful dissection and prevention of injury from the above causes. The early recognition of injury and treatment (which may include medialization of the vocal fold) may prevent aspiration and pneumonia and therefore may be of benefit early in the postoperative course [56, 57].

Other causes of respiratory failure or shortness of breath can include ARDS, cardiac causes, pleural effusions, pneumothorax, phrenic nerve injury, or fistula. Other infections can put patients at risk for ARDS (acute respiratory distress syndrome), and cardiac causes may also result in respiratory failure and need for reintubation. If ARDS occurs, the cause should be evaluated, including examining for other infections (urine, leak, etc.). If cardiac in nature, most commonly secondary to atrial fibrillation, heart rate control is usually necessary to alleviate symptoms. Pleural effusions and pneumothorax are common and can be managed with chest tube placement or percutaneous radiologic drainage, depending on the size of the effusion or pneumothorax. If effusions occur simultaneously with anastomotic leak, adequate drainage should be performed to prevent empyema and life-threatening mediastinitis. While phrenic nerve injury is rare, immediate surgical intervention is not always needed. However, patients may require tracheostomy placement for pulmonary conditioning. It is also important to remember that patients are at an increased risk for deep vein thrombosis and even pulmonary embolism. This may occur prior to or even after esophagectomy. Perioperative prophylactic anticoagulation should be administered in the perioperative setting to prevent deep vein thrombosis/pulmonary embolism. Tracheoesophageal fistula should also be considered, especially later in the recovery period or in a complicated postoperative recovery setting.

Impaired lung function is a significant risk factor for pulmonary complications [8]. With preoperative chemoradiation, pneumonitis can occur, making patients at an increased risk for postoperative respiratory failure and pneumonia [8]. While some degree of inflammation is often seen in preoperative imaging, assuring patient lung function has not decompensated is prudent. This can often cause delays in surgery; however, allowing the recovery of lung function may improve postoperative pulmonary failure.

Consistent with the recommendations of the Enhanced Recovery After Surgery pathways, intravenous fluid administration should be minimized to improve time to return of bowel function and decrease the length of hospital stay. Excessive fluid administration/fluid overload should also be considered in all patients with acute respiratory failure since the administration of diuretics may quickly improve symptoms.

3.3. Anastomotic leak/conduit necrosis

Anastomotic leak after esophagectomy can be difficult to manage and has a major impact on patient quality of life as well as may affect long-term survival [58, 59]. Incidence varies from 5.7 to 14.3% with a higher incidence in cervical anastomoses versus thoracic [60]. The International Study Group for Rectal Cancer proposed the verbiage of anastomotic leak as, “A defect of the integrity in a surgical joint between two hollow viscera with communication between the intraluminal and extraluminal compartments,” which was later validated and expanded to the entire gastrointestinal tract [61]. Lerut et al. with the Surgery Infection Study Group defined anastomotic leak severity as Type 1, a radiological leak without any clinical findings; Type 2 with minor clinical findings of local inflammation (cervical wound) or X-ray showed suppressed leak (thoracic anastomosis); Type 3, a major clinical leak with severe disruption and sepsis; Type 4, conduit necrosis seen by endoscopic confirmation [62]. The Early Complications Consensus Group (ECCG) defined anastomotic leak as a full-thickness GI defect involving esophagus, anastomosis, staple line, or conduit, irrespective of the presentation of the method of identification [3]. Type 1 includes a local defect requiring no change in therapy or treated medically or with dietary modification. Type 2 is a localized defect requiring interventional but not surgical therapy (interventional radiology drainage, stent or bedside opening and packing of incision). Type 3 is a localized defect requiring surgical therapy.

Many patient factors as well as peri- and intraoperative factors can contribute to anastomotic leak. Patients at an increased risk for anastomotic leak include those with increased comorbidities, advanced pathologic stage, prior esophagogastric surgeries, and active smoking [63]. Patient factors can include preoperative malnutrition, diabetes, prolonged hospitalization, hypotension, hypoxemia, preoperative chemotherapy, preoperative chemoradiation, and age. Technical factors also impacting the rate of anastomotic leak include the location of the anastomosis, surgery type, tension on the anastomosis, the type of anastomosis (hand sewn vs. stapled), arterial and venous insufficiency, excessive bleeding, and surgeon experience. While leak incidence may be higher in a single-layer anastomosis, the incidence of stricture may be higher in a double-layer anastomosis [64, 65, 66]. While data are mixed, the incidence of leak and stricture may also be lower with a stapled anastomosis [67, 68]. Postoperative factors may include gastric distention, external compression, infection, re-exploration for bleeding, prolonged mechanical ventilation, and continued hypoxemia and hypotension [69]. Technical considerations to decrease the rate of anastomotic leak may include anastomotic support with omentum, pleura, pericardium, and fat tissue. Prospective randomized studies have shown that omental wrapping of the anastomosis may decrease the rate of leak or even stricture [70, 71].

Diagnosis can be made by clinical suspicion if a patient presents with fevers, leukocytosis, empyema, pleural effusion, pneumomediastinum, increased drainage from the chest tube (bile or other gastric contents), the presence of enteric bacteria or bacterial culture or tachycardia. The early detection of anastomotic leaks may also include CRP/ESR elevation, an increase in procalcitonin level, and leukocytosis extending past the second and fifth postoperative days, respectively [72, 73]. While contrast esophagogram can be performed to determine subclinical leaks, caution is advised given the risks of aspiration [4, 74]. A barium swallow can be performed to detect an anastomotic leak; however, its sensitivity can be relatively low and may often be performed too early to detect [75, 76]. The oral intake of methylene blue may be used given it is otherwise nontoxic. CT scan with oral contrast may also be helpful and show contrast extravasation as well as concerning areas for infection.

The etiology of the leak is vital to ascertain where patients with conduit tip necrosis or complete conduit ischemia may require different interventions. This often requires direct visualization with EGD for conduit evaluation as well as evaluation of the defect size. The ECCG defines conduit necrosis into three types, with recommendations for specific treatments: Type 1 includes a focal conduit necrosis that is identified endoscopically, requiring only additional monitoring or nonsurgical therapy; Type 2 includes focal conduit necrosis that is identified endoscopically and is not associated with free anastomotic or conduit leak. Surgical therapy not involving esophageal diversion is performed; Type 3 includes extensive conduit necrosis that is treated with conduit resection and diversion [3].

If a leak occurs, source control with drain placement with or without operative intervention remains key to preventing mortality. For this reason, intraoperative drain placement for detection and source control is common. Management often is determined by anastomotic location; however, mediastinitis can occur with both intrathoracic and cervical anastomoses, a possibly fatal diagnosis for which requires close monitoring and rapid evaluation and treatment. Turkyilmaz et al. created algorithms to help guide treatment for anastomotic leak. For cervical anastomoses, a limited leak that is clinically occult may be managed with antibiotics, dressing changes, and cleansing with oral isotonic fluid. If there is a clinically prominent cervical leak, antibiotics, opening of the cervical wound, drain placement, nasogastric decompression, nutritional support, and cleaning are typically needed. For cervical anastomotic leaks that have intrathoracic complications and clinical sepsis failing to improve, drain placement, stent placement, decortication, resection/diversion or resection/colonic interposition may be needed. For thoracic anastomoses, if a contained leak with less than 30% disruption, injection with fibrin glue, endoclips, or stents can be used for management. However, if the defect is larger, drainage and esophageal stent placement can be performed followed by surgery if stent placement and drainage are unsuccessful (can include primary or supporting tissue repair). However, if the anastomosis has a greater than 70% disruption, surgery including drainage and primary repair should be performed first with esophageal diversion with possible colonic interposition if unable to be performed [69].

With the use of self-expanding metal stents, endoscopic management alone has become possible for anastomotic leaks/disruptions. Covered stents can be placed to control the leak, preventing further seeding into the mediastinum for both cervical and thoracic anastomoses. If well controlled, oral intake may also be safe. However, stent migration can occur, requiring retrieval and replacement [77]. Stent use may be limited in large defects (which may occur from conduit necrosis or staple line disruption). It is also important to understand that lumen caliber differences between the esophagus and gastric conduit can result in the reflux of gastric contents around the distal aspect of a stent. This unfortunately may not be seen with an esophagogram, but rather be noticed with other imaging such as CT after the reflux of contrast and gastric contents occur and may be delayed. Therefore, other options for control have emerged including endoscopic vacuum-assisted closure devices and may even be more effective than stent placement [78, 79, 80, 81].

3.4. Fistula

In addition to source control, the awareness and prevention of esophago/gastrotracheal fistula is also necessary. This can occur from infection itself or even the erosion of foreign material (stent, staples, etc.) into the trachea. One should be suspicious in patients with frequent uncontrolled coughing, especially after swallowing, or “Ono’s sign” [82]. Workup and diagnosis can include an upper gastrointestinal X-ray with oral contrast or even direct visualization with esophagoscopy or bronchoscopy. Prevention may include a pleural wrap around the anastomosis at the time of original operation or even at the time of reoperation if a leak occurs and anastomotic repair is possible. If reoperation is not performed, stent placement may help control symptoms and healing [83]. However, distal feeding tube placement and resection may be needed. Treatment is necessary to prevent recurring pneumonia.

3.5. Delayed gastric emptying

Delayed or inappropriate gastric emptying can occur secondary to the disruption of vagal nerve complexes to the stomach. This can result in delayed emptying of the stomach, which affects not only patient quality of life and inability to obtain oral nutrition but also can put patients at an increased risk for reflux of gastric contents and even aspiration. The most common options for the management of the pylorus include pyloromyotomy, pyloroplasty, intra-pyloric botulinum toxin injection as well as no intervention. While one multicenter study showed no significant difference between pyloroplasty, botulinum toxin-injection, and no pyloric treatment, one study did show that intra-pyloric botulinum toxin can increase the risk of postoperative reflux and increase the use of promotility agents and endoscopic interventions [84, 85]. While delayed gastric emptying can occur anywhere from 10 to 50%, it also can be successfully managed with prokinetic agents (75%) and endoscopic dilation [86].

3.6. Chyle leak/chylothorax

With the thoracic duct being the largest lymphatic vessel in the body as well as being located in the chest, posterior to the esophagus, injury can occur. Its location, however, often varies. The incidence of chyle leak is rather low (1–4%); however, when it occurs, it can be very problematic [87]. Chyle contains triglycerides in the form of chylomicrons as well as lymphocytes. Chyle leaks can result in malnutrition (with continued protein loss), immune compromise, hypovolemia, electrolyte abnormalities, hypoalbuminemia, lymphopenia, and infection [88]. The ECCG defines a chyle leak into three different types, where output <1 L/day is further classified as “A,” and “B” is further classified as >1 L/day [3]. Type 1 leaks can be managed with enteric dietary modifications alone. Type 2 can be managed with total parenteral nutrition. Type 3 requires management with interventional or surgical therapy.

Following esophagectomy, drainage from a chest tube of >500 mL/day is suggestive of a chyle leak; however, the measurement of chylomicrons or triglycerides is most commonly utilized [89]. A measurement of >4% chylomicrons or fluid containing >100–110 mg/dL of triglycerides is typically considered indicative of a chyle leak. Since a chyle leak may present with increased serous or even serosanguinous drainage while fasting, a clinical diagnosis can be made by the oral intake of cream followed by milky drainage from the chest tube/drains.

Prevention unfortunately is difficult. Selective en masse ligation has been shown to reduce the rate of chylothorax [90]. Also, the preoperative oral administration of cream may help identify the thoracic duct to aid in the prevention of its injury or to identify the thoracic duct for prophylactic ligation [91]. The initial management of a chyle leak usually includes drainage as well as TPN and bowel rest. Decreasing oral or enteral fat intake decreases the flow of chyle through the leak, possibly allowing spontaneous closure [92]. Long chain fatty acids should be avoided with diets supported by high percentages of medium-chain triglycerides since they are typically absorbed directly into intestinal cells, bypassing the thoracic duct [87]. If conservative management is not successful, surgical intervention may be necessary, especially if the fistula is of high output. Aggressive surgical intervention should be performed if chyle output is >1.5 L/day for >5–7 days [93]. Surgical intervention includes thoracotomy or thoracoscopic thoracic duct ligation on the side of the chylothorax. This is usually assisted by the preoperative administration of cream or lipophilic dye to help identify the thoracic duct. If the leak can be localized, this may be controlled with clips or suture; however, if the leak is unclear, ligation of the thoracic duct just cephalad to the aortic hiatus is recommended [94, 95, 96]. Pleurodesis can also be performed at the time of ligation as well.

Radiologic-guided/percutaneous embolization is becoming more popular, especially for patients who are poor operative candidates. This includes lymphangiography followed by transabdominal percutaneous needle cannulation, although a retrograde subclavian vein approach can be used [97, 98]. Once the cisterna chyli is canalized, a catheter is advanced into the thoracic duct and contrast used to identify the leak. Embolization can then be performed. Since surgical intervention to ligate the thoracic duct using thoracoscopy or a thoracotomy can result in increased morbidity and mortality, thoracic duct embolization has become increasingly more popular when conservative management fails.

References

  1. 1. Kataoka K, Takeuchi H, Mizusawa J, et al. Prognostic impact of postoperative morbidity after esophagectomy for esophageal cancer: Exploratory analysis of JCOG9907. Annals of Surgery. 2017;265(6):1152-1157. DOI: 10.1097/SLA.0000000000001828
  2. 2. Lerut T, Moons J, Coosemans W, et al. Postoperative complications after transthoracic esophagectomy for cancer of the esophagus and gastroesophageal junction are correlated with early cancer recurrence: Role of systematic grading of complications using the modified clavien classification. Annals of Surgery. 2009;250(5):798-806. DOI: 10.1097/SLA.0b013e3181bdd5a8
  3. 3. Low DE, Alderson D, Cecconello I, et al. International consensus on standardization of data collection for complications associated with esophagectomy: Esophagectomy complications consensus group (ECCG). Annals of Surgery. 2015;262(2):286-294. DOI: 10.1097/SLA.0000000000001098
  4. 4. Griffin SM, Lamb PJ, Dresner SM, Richardson DL, Hayes N. Diagnosis and management of a mediastinal leak following radical oesophagectomy. The British Journal of Surgery. 2001;88(10):1346-1351. DOI: 10.1046/j.0007-1323.2001.01918.x
  5. 5. Law S, Wong K, Kwok K, Chu K, Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Annals of Surgery. 2004;240(5):791-800. DOI: 10.1097/01.sla.0000143123.24556.1c
  6. 6. Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity and mortality following esophagectomy. The Annals of Thoracic Surgery. 2004;78(4):1170-1176. DOI: 10.1016/j.athoracsur.2004.02.034
  7. 7. Bailey SH, Bull DA, Harpole DH, et al. Outcomes after esophagectomy: A ten-year prospective cohort. The Annals of Thoracic Surgery. 2003;75(1):217-222. DOI: 10.1016/S0003-4975(02)04368-0
  8. 8. Avendano CE, Flume PA, Silvestri GA, King LB, Reed CE. Pulmonary complications after esophagectomy. The Annals of Thoracic Surgery. 2002;73(3):922-926. DOI: 10.1016/S0003-4975(01)03584-6
  9. 9. Kinugasa S, Tachibana M, Yoshimura H, et al. Postoperative pulmonary complications are associated with worse short- and long-term outcomes after extended esophagectomy. Journal of Surgical Oncology. 2004;88(2):71-77. DOI: 10.1002/jso.20137
  10. 10. Raymond DP, Seder CW, Wright CD, et al. Predictors of major morbidity or mortality after resection for esophageal cancer: A society of thoracic surgeons general thoracic surgery database risk adjustment model. The Annals of Thoracic Surgery. 2016;102(1):207-214. DOI: 10.1016/j.athoracsur.2016.04.055
  11. 11. Ferguson MK, Martin TR, Reeder LB, Olak J. Mortality after esophagectomy: Risk factor analysis. World Journal of Surgery. 1997;21(6):599-604. DOI: 10.1007/s002689900279
  12. 12. Kim JY, Correa AM, Vaporciyan AA, et al. Does the timing of esophagectomy after chemoradiation affect outcome? The Annals of Thoracic Surgery. 2012;93(1):207-212; discussion 212-3. DOI: 10.1016/j.athoracsur.2011.05.021
  13. 13. Daly JM, Fry WA, Little AG, et al. Esophageal cancer: Results of American college of surgeons patient care evaluation study. Journal of the American College of Surgeons. 2000;190(5):562-573
  14. 14. Dewys WD, Begg C, Lavin PT, et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern cooperative oncology group. The American Journal of Medicine. 1980;69(4):491-497
  15. 15. Mariette C, De Botton M, Piessen G. Surgery in esophageal and gastric cancer patients: What is the role for nutrition support in your daily practice? Annals of Surgical Oncology. 2012;19(7):2128-2134. DOI: 10.1245/s10434-012-2225-6
  16. 16. Nitenberg G, Raynard B. Nutritional support of the cancer patient: Issues and dilemmas. Critical Reviews in Oncology/Hematology. 2000;34(3):137-168. DOI: 10.1016/S1040-8428(00)00048-2
  17. 17. Odelli C, Burgess D, Bateman L, et al. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clinical Onco-logy. 2005;17(8):639-645. DOI: 10.1016/j.clon.2005.03.015
  18. 18. Beale RJ, Bryg DJ, Bihari DJ. Immunonutrition in the critically ill: A systematic review of clinical outcome. Critical Care Medicine. 1999;27(12):2799-2805. DOI: 10.1097/00003246-199912000-00032
  19. 19. Heys SD, Walker LG, Smith I, Eremin O. Enteral nutritional supplementation with key nutrients in patients with critical illness and caner: A meta-analysis of randomized controlled clinical trials. Nutrition Clinique et Metabolisme. 2000;14(1):62-63
  20. 20. Adler DG, Fang J, Wong R, Wills J, Hilden K. Placement of polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy. Gastrointestinal Endoscopy. 2009;70(4):614-619. DOI: 10.1016/j.gie.2009.01.026
  21. 21. Langer FB, Schoppmann SF, Prager G, et al. Temporary placement of self-expanding oesophageal stents as bridging for neo-adjuvant therapy. Annals of Surgical Oncology. 2010;17(2):470-475. DOI: 10.1245/s10434-009-0760-6
  22. 22. Srinathan SK, Hamin T, Walter S, Tan AL, Unruh HW, Guyatt G. Jejunostomy tube feeding in patients undergoing esophagectomy. Canadian Journal of Surgery. 2013;56(6):409-414. DOI: 10.1503/cjs.008612
  23. 23. Fenton JR, Bergeron EJ, Coello M, Welsh RJ, Chmielewski GW. Feeding jejunostomy tubes placed during esophagectomy: Are they necessary? The Annals of Thoracic Surgery. 2011;92(2):504-11; discussion 511-2. DOI: 10.1016/j.athoracsur.2011.03.101
  24. 24. Weijs TJ, van Eden HWJ, Ruurda JP, et al. Routine jejunostomy tube feeding following esophagectomy. Journal of Thoracic Disease. 2017;9:S851-S860. DOI: 10.21037/jtd.2017.06.73
  25. 25. Yoshida N, Baba Y, Hiyoshi Y, et al. Duration of smoking cessation and postoperative morbidity after esophagectomy for esophageal cancer: How long should patients stop smoking before surgery? World Journal of Surgery. 2016;40(1):142-147. DOI: 10.1007/s00268-015-3236-9
  26. 26. Mantziari S, Allemann P, Winiker M, Demartines N, Schäfer M. Locoregional tumor extension and preoperative smoking are significant risk factors for early recurrence after esophagectomy for cancer. World Journal of Surgery. 2017;42(7):2209-2217. DOI: 10.1007/s00268-017-4422-8
  27. 27. Brusselaers N, Mattsson F, Lagergren J. Hospital and surgeon volume in relation to long-term survival after oesophagectomy: Systematic review and meta-analysis. Gut. 2014;63(9):1393-1400. DOI: 10.1136/gutjnl-2013-306074
  28. 28. Varghese TK, Wood DE, Farjah F, et al. Variation in esophagectomy outcomes in hospitals meeting leapfrog volume outcome standards. The Annals of Thoracic Surgery. 2011;91(4):1003-1009. DOI: 10.1016/j.athoracsur.2010.11.006
  29. 29. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. Journal of the American Medical Association. 1998;280(20):1747-1751
  30. 30. Birkmeyer JD, Lucas FL, Wennberg DE. Potential benefits of regionalizing major surgery in medicare patients. Effective Clinical Practice. 1999;2(6):277-283
  31. 31. Birkmeyer JD, Dimick JB. Potential benefits of the new leapfrog standards: Effect of process and outcomes measures. Surgery. 2004;135(6):569-575. DOI: 10.1016/j.surg.2004.03.004
  32. 32. McCahill LE, May M, Morrow JB, et al. Esophagectomy outcomes at a mid-volume cancer center utilizing prospective multidisciplinary care and a 2-surgeon team approach. American Journal of Surgery. 2014;207(3):380-386. DOI: 10.1016/j.amjsurg.2013.09.013
  33. 33. Kauppila JH, Wahlin K, Lagergren P, Lagergren J. University hospital status and surgeon volume and risk of reoperation following surgery for esophageal cancer. European Journal of Surgical Oncology. 2018;44(5):632-637. DOI: 10.1016/j.ejso.2018.02.212
  34. 34. Varagunam M, Hardwick R, Riley S, Chadwick G, Cromwell DA, Groene O. Changes in volume, clinical practice and outcome after reorganisation of oesophago-gastric cancer care in England: A longitudinal observational study. European Journal of Surgical Oncology. 2018;44(4):524-531. DOI: 10.1016/j.ejso.2018.01.001
  35. 35. Hummel R, Ha NH, Lord A, Trochsler MI, Maddern G, Kanhere H. Centralisation of oesophagectomy in Australia: Is only caseload critical? Australian Health Review. 2017. DOI: 10.1071/AH17095
  36. 36. Michael Griffin S, Shaw IH, Dresner SM. Early complications after ivorlewis subtotal esophagectomy with two-field lymphadenectomy: Risk factors and management. Journal of the American College of Surgeons. 2002;194(3):285-297. DOI: 10.1016/S1072-7515(01)01177-2
  37. 37. Funk LM, Gawande AA, Semel ME, et al. Esophagectomy outcomes at low-volume hospitals: The association between systems characteristics and mortality. Annals of Surgery. 2011;253(5):912-917. DOI: 10.1097/SLA.0b013e318213862f
  38. 38. Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high-volume hospitals: Estimating potentially avoidable deaths. Journal of the American Medical Association. 2000;283(9):1159-1166
  39. 39. Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States. New England Journal of Medicine. 2002;346(15):1128-1137. DOI: 10.1056/NEJMsa012337
  40. 40. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Annals of Internal Medicine. 2002;137(6):511-520
  41. 41. Amaravadi RK, Dimick JB, Pronovost PJ, Lipsett PA. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Medicine. 2000;26(12):1857-1862. DOI: 10.1007/s001340000720
  42. 42. Pennathur A, Farkas A, Krasinskas AM, et al. Esophagectomy for T1 esophageal cancer: Outcomes in 100 patients and implications for endoscopic therapy. The Annals of Thoracic Surgery. 2009;87(4):1048-1055. DOI: 10.1016/j.athoracsur.2008.12.060
  43. 43. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: Review of over 1000 patients. Annals of Surgery. 2012;256(1):95-103. DOI: 10.1097/SLA.0b013e3182590603
  44. 44. Luketich JD, Pennathur A, Franchetti Y, et al. Minimally invasive esophagectomy: Results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study. Annals of Surgery. 2015;261(4):702-707. DOI: 10.1097/SLA.0000000000000993
  45. 45. Sarkaria IS, Rizk NP, Grosser R, et al. Attaining proficiency in robotic-assisted minimally invasive esophagectomy while maximizing safety during procedure development. Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery. 2016;11(4):268-273. DOI: 10.1097/IMI.0000000000000297
  46. 46. Junginger T, Gockel I, Heckhoff S. A comparison of transhiatal and transthoracic resections on the prognosis in patients with squamous cell carcinoma of the esophagus. European Journal of Surgical Oncology. 2006;32(7):749-755. DOI: 10.1016/j.ejso.2006.03.048
  47. 47. Stawicki SPA, Prosciak MP, Gerlach AT, et al. Atrial fibrillation after esophagectomy: An indicator of postoperative morbidity. General Thoracic and Cardiovascular Surgery. 2011;59(6):399-405. DOI: 10.1007/s11748-010-0713-9
  48. 48. Lohani KR, Nandipati KC, Rollins SE, et al. Transthoracic approach is associated with increased incidence of atrial fibrillation after esophageal resection. Surgical Endoscopy. 2015;29(7):2039-2045. DOI: 10.1007/s00464-014-3908-9
  49. 49. Seesing MFJ, Scheijmans JCG, Borggreve AS, van Hillegersberg R, Ruurda JP. The predictive value of new-onset atrial fibrillation on postoperative morbidity after esophagectomy. Diseases of the Esophagus. 2018. DOI: 10.1093/dote/doy028
  50. 50. Turagam MK, Downey FX, Kress DC, Sra J, Tajik AJ, Jahangir A. Pharmacological strategies for prevention of postoperative atrial fibrillation. Expert Review of Clinical Pharmacology. 2015;8(2):233-250. DOI: 10.1586/17512433.2015.1018182
  51. 51. Tisdale JE, Wroblewski HA, Wall DS, et al. A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy. The Journal of Thoracic and Cardiovascular Surgery. 2010;140(1):45-51. DOI: 10.1016/j.jtcvs.2010.01.026
  52. 52. Fabian T, Rassias DJ, Daneshmand MA, Ilves R. Amiodarone for atrial fibrillation prophylaxis in patients undergoing esophagectomy. Chest. 2004;126(4):800S
  53. 53. Fernando HC, Jaklitsch MT, Walsh GL, et al. The society of thoracic surgeons practice guideline on the prophylaxis and management of atrial fibrillation associated with general thoracic surgery: Executive summary. The Annals of Thoracic Surgery. 2011;92(3):1144-1152. DOI: 10.1016/j.athoracsur.2011.06.104
  54. 54. Kalil AC, Metersky ML, Klompas M, et al. Executive summary: Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of America and the American thoracic society. Clinical Infectious Diseases. 2016;63(5):575-582. DOI: 10.1093/cid/ciw504
  55. 55. Weijs TJ, Seesing MFJ, van Rossum PSN, et al. Internal and external validation of a multivariable model to define hospital-acquired pneumonia after esophagectomy. Journal of Gastrointestinal Surgery. 2016;20(4):680-687. DOI: 10.1007/s11605-016-3083-5
  56. 56. Bhattacharyya N, Batirel H, Swanson SJ. Improved outcomes with early vocal fold medialization for vocal fold paralysis after thoracic surgery. Auris, Nasus, Larynx. 2003;30(1):71-75. DOI: 10.1016/S0385-8146(02)00114-1
  57. 57. Scholtemeijer MG, Seesing MFJ, Brenkman HJF, Janssen LM, van Hillegersberg R, Ruurda JP. Recurrent laryngeal nerve injury after esophagectomy for esophageal cancer: Incidence, management, and impact on short- and long-term outcomes. Journal of Thoracic Disease. 2017;9(Suppl 8):S868-S878. DOI: 10.21037/jtd.2017.06.92 [doi]
  58. 58. Sierzega M, Kolodziejczyk P, Kulig J. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. The British Journal of Surgery. 2010;97(7):1035-1042. DOI: 10.1002/bjs.7038
  59. 59. Rizk NP, Ishwaran H, Rice TW, et al. Optimum lymphadenectomy for esophageal cancer. Annals of Surgery. 2010;251(1):46-50. DOI: 10.1097/SLA.0b013e3181b2f6ee
  60. 60. Kassis ES, Kosinski AS, Ross P, Koppes KE, Donahue JM, Daniel VC. Predictors of anastomotic leak after esophagectomy: An analysis of the society of thoracic surgeons general thoracic database. The Annals of Thoracic Surgery. 2013;96(6):1919-1926. DOI: 10.1016/j.athoracsur.2013.07.119
  61. 61. Chadi SA, Fingerhut A, Berho M, et al. Emerging trends in the etiology, prevention, and treatment of gastrointestinal anastomotic leakage. Journal of Gastrointestinal Surgery. 2016;20(12):2035-2051. DOI: 10.1007/s11605-016-3255-3
  62. 62. Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, Van Raemdonck D. Anastomotic complications after esophagectomy. Digestive Surgery. 2002;19(2):92-98. DOI: 10.1159/000052018
  63. 63. Cooke DT, Lin GC, Lau CL, et al. Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy: Risk factors, presentation, and detection. The Annals of Thoracic Surgery. 2009;88(1):177-185. DOI: 10.1016/j.athoracsur.2009.03.035
  64. 64. Wilson SE, Stone R, Scully M, Ozeran L, Benfield JR. Modern management of anastomotic leak after esophagogastrectomy. American Journal of Surgery. 1982;144(1):95-101. DOI: 10.1016/0002-9610(82)90608-0
  65. 65. Mathisen DJ, Grillo HC, Wilkins EW Jr, Moncure AC, Hilgenberg AD. Transthoracic esophagectomy: A safe approach to carcinoma of the esophagus. The Annals of Thoracic Surgery. 1988;45(2):137-143
  66. 66. Postlethwait RW. Complications and deaths after operations for esophageal carcinoma. The Journal of Thoracic and Cardiovascular Surgery. 1983;85(6):827-831
  67. 67. Okuyama M, Motoyama S, Suzuki H, Saito R, Maruyama K, Ogawa J. Hand-sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer: A prospective randomized controlled study. Surgery Today. 2007;37(11):947-952. DOI: 10.1007/s00595-007-3541-5
  68. 68. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. The Journal of Thoracic and Cardiovascular Surgery. 2000;119(2):277-288. DOI: 10.1016/S0022-5223(00)70183-8
  69. 69. Turkyilmaz A, Eroglu A, Aydin Y, Tekinbas C, Muharrem Erol M, Karaoglanoglu N. The management of esophagogastric anastomotic leak after esophagectomy for esophagealcarcinoma. Diseases of the Esophagus. 2009;22(2):119-126. DOI: 10.1111/j.1442-2050.2008.00866.x
  70. 70. Dai JG, Zhang ZY, Min JX, Huang XB, Wang JS. Wrapping of the omental pedicle flap around esophagogastric anastomosis after esophagectomy for esophageal cancer. Surgery (USA). 2011;149(3):404-410. DOI: 10.1016/j.surg.2010.08.005
  71. 71. Bhat MA, Dar MA, Lone GN, Dar AM. Use of pedicledomentum in esophagogastric anastomosis for prevention of anastomotic leak. The Annals of Thoracic Surgery. 2006;82(5):1857-1862. DOI: 10.1016/j.athoracsur.2006.05.101
  72. 72. Deitmar S, Anthoni C, Palmes D, Haier J, Senninger N, Brüwer M. Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection? Zentralblatt für Chirurgie. 2009;134(1):83-89. DOI: 10.1055/s-0028-1098768
  73. 73. Veeramootoo D, Parameswaran R, Krishnadas R, et al. Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy. Surgical Endoscopy. 2009;23(9):2110-2116. DOI: 10.1007/s00464-008-0233-1
  74. 74. Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. The British Journal of Surgery. 1998;85(10):1446-1449. DOI: 10.1046/j.1365-2168.1998.00869.x
  75. 75. Roh S, Iannettoni MD, Keech JC, Bashir M, Gruber PJ, Parekh KR. Role of barium swallow in diagnosing clinically significant anastomotic leak following esophagectomy. Korean Journal of Thoracic and Cardiovascular Surgery. 2016;49(2):99-106. DOI: 10.5090/kjtcs.2016.49.2.99
  76. 76. Andreou A, Struecker B, Biebl M, Pratschke J. Routine barium swallow may be unnecessary after resection of esophageal cancer. Journal of the American College of Surgeons. 2015;221(4):S145. DOI: 10.1016/j.jamcollsurg.2015.07.347
  77. 77. Kauer WKH, Stein HJ, Dittler H, Siewert JR. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Surgical Endoscopy. 2008;22(1):50-53. DOI: 10.1007/s00464-007-9504-5
  78. 78. Brangewitz M, Voigtländer T, Helfritz FA, et al. Endoscopic closure of esophageal intrathoracic leaks: Stent versus endoscopic vacuum-assisted closure, a retrospective analysis. Endoscopy. 2013;45(6):433-438. DOI: 10.1055/s-0032-1326435
  79. 79. Ahrens M, Schulte T, Egberts J, et al. Drainage of esophageal leakage using endoscopic vacuum therapy: A prospective pilot study. Endoscopy. 2010;42(9):693-698. DOI: 10.1055/s-0030-1255688
  80. 80. Wedemeyer J, Brangewitz M, Kubicka S, et al. Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system. Gastrointestinal Endoscopy. 2010;71(2):382-386. DOI: 10.1016/j.gie.2009.07.011
  81. 81. Mennigen R, Harting C, Lindner K, et al. Comparison of endoscopic vacuum therapy versus stent for anastomotic leak after esophagectomy. Journal of Gastrointestinal Surgery. 2015;19(7):1229-1235. DOI: 10.1007/s11605-015-2847-7
  82. 82. Diddee R, Shaw IH. Acquired tracheo-oesophageal fistula in adults. Continuing Education in Anaesthesia Critical Care & Pain. 2006;6(3):105-108. DOI: 10.1093/bjaceaccp/mkl019
  83. 83. Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. The Annals of Thoracic Surgery. 2010;89(3):931-937. DOI: 10.1016/j.athoracsur.2009.10.061
  84. 84. Marchese S, Qureshi YA, Hafiz SP, et al. Intraoperative pyloric interventions during oesophagectomy: A multicentre study. Journal of Gastrointestinal Surgery. 2018:1-6. DOI: 10.1007/s11605-018-3759-0
  85. 85. Eldaif SM, Lee R, Adams KN, et al. Intrapyloric botulinum injection increases postoperative esophagectomy complications. The Annals of Thoracic Surgery. 2014;97(6):1959-1965. DOI: 10.1016/j.athoracsur.2013.11.026
  86. 86. Zhang L, Hou S, Miao J, Lee H. Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage. The Journal of Surgical Research. 2017;213:46-50. DOI: 10.1016/j.jss.2017.02.012
  87. 87. Smoke A, Delegge MH. Chyle leaks: Consensus on management? Nutrition in Clinical Practice. 2008;23(5):529-532. DOI: 10.1177/0884533608323424
  88. 88. Jensen GL, Mascioli EA, Meyer LP, et al. Dietary modification of chyle composition in chylothorax. Gastroenterology. 1989;97(3):761-765. DOI: 10.1016/0016-5085(89)90650-1
  89. 89. Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. The British Journal of Surgery. 1998;85(8):1147-1149. DOI: 10.1046/j.1365-2168.1998.00819.x
  90. 90. Lin Y, Li Z, Li G, et al. Selective en masse ligation of the thoracic duct to prevent chyle leak after esophagectomy. The Annals of Thoracic Surgery. 2017;103(6):1802-1807
  91. 91. Shackcloth MJ, Poullis M, Lu J, Page RD. Preventing of chylothorax after oesophagectomy by routine pre-operative administration of oral cream. European Journal of Cardio-Thoracic Surgery. 2001;20(5):1035-1036. DOI: 10.1016/S1010-7940(01)00928-9
  92. 92. Sriram K, Meguid RA, Meguid MM. Nutritional support in adults with chyle leaks. Nutrition. 2016;32(2):281-286. DOI: 10.1016/j.nut.2015.08.002
  93. 93. Browse NL, Allen DR, Wilson NM. Management of chylothorax. The British Journal of Surgery. 1997;84(12):1711-1716. DOI: 10.1046/j.1365-2168.1997.02858.x
  94. 94. Martucci N, Tracey M, Rocco G. Postoperative chylothorax. Thoracic Surgery Clinics. Nov. 2015;25(4):523-528
  95. 95. Zabeck H, Muley TF, Dienemann HF, Hoffmann H. Management of chylothorax in adults: When is surgery indicated? The Thoracic and Cardiovascular Surgeon. 2011; 59(4): 243-246
  96. 96. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. European Journal of Cardio-Thoracic Surgery. 2007;32(2):362-369. DOI: 10.1016/j.ejcts.2007.04.024
  97. 97. Pamarthi V, Stecker MS, Schenker MP, et al. Thoracic duct embolization and disruption for treatment of chylous effusions: Experience with 105 patients. Journal of Vascular and Interventional Radiology. 2014;25(9):1398-1404. DOI: 10.1016/j.jvir.2014.03.027
  98. 98. Guevara CJ, Rialon KL, Ramaswamy RS, Kim SK, Darcy MD. US-guided, direct puncture retrograde thoracic duct access, lymphangiography, and embolization: Feasibility and efficacy. Journal of Vascular and Interventional Radiology. Dec. 2016;27(12):1890-1896

Written By

Jacqueline Oxenberg

Submitted: 19 February 2018 Reviewed: 16 May 2018 Published: 05 November 2018