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convex surface of the liver [ 1 , 2 ]. The thoracic duct originates at the cisterna chyli
that lies at the body of the second lumbar vertebrae. Varying in length from 37 to
45 cm, the thoracic duct ascends into the thorax through the diaphragmatic hiatus,
posterior to the median arcuate ligament, between the azygos vein and the aorta.
It crosses to the left side of the thorax at a variable level between the sixth and
fourth thoracic vertebrae to continue its ascent to the left of the esophagus. It
passes posterior to the aortic arch and then anterior to the subclavian artery to
enter the neck via the superior thoracic aperture to join the left subclavian vein at
its junction with the internal jugular vein [ 2 ]. While this is the classical course,
considerable variation may be found, which are reported to occur in approximately half of the population [ 3 ]. There are numerous valves throughout the
length of the duct and at the lymphatico- venous junction with the left subclavian
vein.
A.M. Isla et al.
Complications of Chyle Loss
Local pressure effects of a chylothorax can produce cardiorespiratory compromise.
Following appropriate drainage, prolonged leakage can result in wide ranging
metabolic, nutritional, and immunological complications [ 1 – 3 ]. Maintaining
adequate intravascular volume and accurate fl uid replacement is diffi cult in patients
with chyle leaks. The most frequently observed electrolyte abnormalities are
acidosis, hyponatraemia, and hypocalcaemia [ 1 , 2 ]. Patients rapidly become
nutritionally deplete and require nutritional support. Cell-mediated immunity and
humoral responses are both impaired by ongoing chyle loss due to the loss of
lymphocytes and immunoglobulins [ 1 , 2 ].
Mechanism of Thoracic Duct Injury
The thoracic duct is notoriously diffi cult to visualize at both open and thoracoscopic
surgery. Blunt dissection associated with a traditional open transhiatal
oesophagectomy, for example, can produce shearing forces that injure the fragile
thoracic duct. It is now a well-recognized complication of thoracic and esophageal
surgery with a reported incidence in esophagectomy of approximately 2–4 % [ 1 ].
However, inadvertent injury has been reported in cardiothoracic surgery, neck
surgery, trauma, central venous insertion, and radical nephrectomy [ 1 ]. Preoperative
administration of an oral diet rich in fat (e.g., double cream) can enable easier
identifi cation of the thoracic duct and may reduce the chance of injury through
inadvertent transection or laceration [ 4 ]. Thoracic duct injury may present with a
right or left chylothorax. The side may be a guide to the location of the injury, as an
injury below T5-T6 usually presents with a right-sided chylothorax and that above
this level presents with a left-sided chylothorax [
3 , 5 ].
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Prevention of Thoracic Duct Injury
Various preventative strategies have been employed to avoid chyle leaks. The only
randomized trial of preventive techniques involved the application of fi brin glue
to the mediastinal dissection. Interestingly, this actually demonstrated a signifi cant increase in the lymph leakage. Others have attempted routine ligation of the
thoracic duct. Systematic ligation of mass ligation proved safe and effective. It minimized the risk of postoperative chylothorax in patients who underwent transthoracic
esophagectomy for cancer [ 6 ].
Diagnosis
In the majority of postoperative patients, a chyle leak presents as excessive drainage
(more than 500 mL) of straw or cream-colored fl uid from the chest drain (or abdominal drain in patients who have undergone transhiatal oesophagectomy). In patients
without a postoperative chest drain in situ, signs and symptoms of a pleural effusion
with progressive cardiorespiratory deterioration are the most common presentation
[ 1 ]. There is frequently a refractory period of 2–10 days before the presence of
chyle in the drains. The diagnosis may be further delayed as straw-colored chest
drain fl uid is a normal occurrence, and the classical milky chyle may not be apparent in a fasting patient. The diagnosis therefore requires a high index of suspicion.
It is the authors’ experience that if there is persistent and excessive drainage from
the thorax, enteral administration of double cream may turn the drain output milky,
thereby confi rming the diagnosis [ 4 ]. High concentration of lymphocytes and tri-
glycerides is highly suggestive of a chyle leak, and diagnosis can be confi rmed by
the fi nding of chylomicrons on electrophoresis of the drain fl uid [ 1 ].
Treatment Options
Conservative Treatment
Traditional conservative management of chylothorax involved drainage of the
pleural cavity, measures to reduce chyle fl ow, adjunctive treatments such as somatostatin analogues, nutritional support, and prompt management of septic complications. Chyle fl ow can be substantially reduced by withholding dietary fat intake,
with the exception of medium chain triglycerides (absorbed directly into the circulation, bypassing the lacteal system). Total parental nutrition is an alternative method
of nutritional support, favored in patients with on-going high chyle losses or foregut
reconstructive surgery [
conservative management with patients frequently succumbing to overwhelming
1 ]. Nevertheless, there is a high mortality associated with
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Fig. 3.4 Thoracic duct
crossing the aorta showing
place injury and clipped
proximally
A.M. Isla et al.
infection. The thoracic duct has numerous lymphatico-venous anastomoses with the
azygos, intercostal, and lumbar veins. This allows for surgical intervention with
ligation above and below a thoracic duct injury at any point in the neck or chest
without concern. While a brief period of conservative management may be appropriate for relatively low output chyle leaks, drain outputs >10 mL/kg/day are unlikely
to resolve and therefore surgical intervention should be undertaken.
Surgical Treatment
Preoperative imaging may be of value in the assessment of the thoracic duct
injury and various methods are advocated, including computed tomography,
magnetic resonance imaging, lymphoscintigraphy, and lymphangiography [
1 , 4 ].
The traditional surgical approach was via a thoracotomy. The mainstay of surgical
treatment is now with a minimally invasive thoracoscopic approach. Preoperative
double cream administration aids identifi cation of the thoracic duct. Following
identifi cation of the leak, control is achieved by application of a laparoscopic clip
to the thoracic duct (Fig. 3.4 , Illustration 3.1 ). In patients in whom the leak cannot
be isolated, it has been recommended that the duct be identifi ed and ligated more
proximally, at the level of the diaphragm, while some authors advocate pleurodesis,
pleurectomy, or pleura-peritoneal shunting [
7 ].
Complications of Chyle Leaks
Conservative approaches to the management of chyle leaks had a mortality of
approximately 50 %. Surgical ligation of the duct dramatically reduced this
mortality, and minimally invasive, thoracoscopic approaches have further reduced
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Illustration 3.1 There are
different mechanisms for
lesion of the thoracic duct.
Once indication for surgery is
made, thoracoscopic
identifi cation of the leakage
and clipping of the duct is the
treatment of choice
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the associated mortality. A review of the reported cases in the literature from 2007
demonstrated an overall mortality of 18 %, 23 % for conservative management
(range 0–57 %), and 15 % for surgical intervention (by thoracotomy) [ 4 ]. A case
series of thoracoscopic intervention reported no mortality and minimal morbidity
with this approach [ 2 ]. Percutaneous catheterization and embolization of the tho-
racic duct is a modern interventional approach, and though still in its infancy, good
results have been reported [ 8 ]. However, the failure rate of this technique is
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A.M. Isla et al.
approximately 30 %, and the procedure can delay defi nitive surgical management
[ 8 ]. Hence, minimally invasive surgical ligation for thoracic duct remains a vital
tool in the armory for the esophageal and thoracic surgeon in managing
chylothorax.
References
1. Wemyss-Holden SA, Launois B, Maddern GJ. Management of thoracic duct injuries after
oesophagectomy. Br J Surg. 2001;88:1442–8.
2. Merrigan BA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg. 1997;84:15–20.
3. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J
Cardiothorac Surg. 2007;32:362–9.
4. Valenti V, Martinez-Cecilia D, Gil A, Martinez-Isla A. Thoracoscopic treatment of post surgi-
cal chylothorax after the oral administration of a fat-rich diet. Cir Esp. 2008;84:51–2.
5. Orringer MB, Bluett M, Deeb GM. Aggressive treatment of chylothorax complicating transhia-
tal esophagectomy without thoracotomy. Surgery. 1988;104:720–6.
6. Lai FC, Chen L, Tu YR, et al. Prevention of chylothorax complicating extensive esophageal
resection by mass ligation of thoracic duct: a random control study. Ann Thorac Surg.
2011;91:1770–4.
7. Denk PM, Gatta P, Swanstrom LL. Multimedia article. Prone thoracoscopic thoracic duct liga-
tion for postsurgical chylothorax. Surg Endosc. 2008;22:2742.
8. Hayden JD, Sue-Ling HM, Sarela AI, Dexter SP. Minimally invasive management of chylous
fi stula after oesophagectomy. Dis Esophagus. 2007;20:251–5.
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Case on Postoperative Hiatal Herniation
After Esophageal Resection
Surya S. A. Y. Biere
Keywords Postoperative hiatal herniation • Esophageal resection • Esophageal
cancer • Cervical anastomosis • Esophagectomy
Diagnosis and Indication for Surgery
A 56-year-old female was evaluated for dysphagia, revealing an adenocarcinoma
of the distal esophagus. The tumor could not be assessed with endosonography
because of luminal stenosis. A CT scan and PET-CT scan stage the tumor as
cTxN1M0. The patient received neoadjuvant chemoradiotherapy.
Operation
Subsequently, a three stage open transthoracic esophagectomy with a cervical
anastomosis was performed.
Pathology
Radically resected T3N1 adenocarcinoma. Two out of 17 lymph nodes showed
metastasis. The circumferential resection margin was 3 mm.
S. S. A. Y. Biere , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: s.biere@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_4,
© Springer International Publishing Switzerland 2014
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Fig. 4.1 Aspect of the bowel
herniation on the Thorax
X-ray
Fig. 4.2 CT scan thorax and
herniation
S.S.A.Y. Biere
Postoperative Course: Identifi cation
and Treatment of the Complication
Progressively, during the fi rst two postoperative days, the patient developed an
increasing pleural effusion of the left hemithorax on the chest radiograph (Fig. 4.1 ).
A CT scan on the 3rd day revealed a hiatal herniation of the small bowel, renouncing the image on the chest radiograph (Fig. 4.2 ). A relaparotomy was performed.
4 Case on Postoperative Hiatal Herniation After Esophageal Resection
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Fig. 4.3 Aspect of the
herniated bowel during
laparotomy after reposition
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The bowel was reduced, being vital and a hiatal plasty was performed (Fig. 4.3 ).
The patient could be discharged on the 30th postoperative day.
Discussion
Hiatal herniation is a rare complication after transthoracic esophageal resection for
cancer. A report of 355 patients demonstrated an incidence of hiatal herniation of
3.5 % [ 1 ]. The median time to diagnosis was 8 months. Another series of 218 patients
showed an incidence of hiatal herniation of 4 % of which only 2 % occurred during
the fi rst week after surgery [ 2 ]. In the case presented above, the hiatal herniation
occurred at the third day postoperatively and was associated with intestinal obstruction and strangulation. Radiological assessment such as a chest radiograph and a
CT scan are essential in the diagnosis of hiatal herniation, although in this case
the chest radiograph was misleading. Management should include reduction of the
hernia by laparotomy and approximation of the hiatal defect with—if necessary—a
mesh, which is rarely necessary (Illustration 4.1a, b ) [ 2 ]. An important factor is the
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S.S.A.Y. Biere
enlargement of the hiatus performed during the operation, although this is not a
standard procedure in transthoracic esophagectomy compared to transhiatal esophagectomy [ 3 ]. Prevention of this complication by narrowing of the diaphragmatic
opening and some form of fi xation of the gastric conduit to the hiatus may be indicated to avoid this complication. Awareness of its possible occurrence may help
prevent the development of intestinal obstruction and strangulation.
Illustration 4.1
( a , b ) Hiatal herniation with
incarceration of small bowel
in the left hemithorax.
Reduction by laparotomy
with approximation of the
hiatus
a
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Illustration 4.1 (continued)
b
References
1. Vallböhmer D, Hölscher AH, Herbold T, et al. Diaphragmatic hernia after conventional or
laparoscopic-assisted transthoracic esophagectomy. Ann Thorac Surg. 2007;84:1847–52.
2. Schieman C, Grondin SC. Paraesophageal hernia: clinical presentation, evaluation, and man-
agement controversies. Thorac Surg Clin. 2009;19:473–84.
3. van Sandick JW, Knegjens JL, van Lanschot JJ, Obertop H. Diaphragmatic herniation follow-
ing oesophagectomy. Br J Surg. 1999;86:109–12.
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