Endoscopic Management of Persistent Chylothorax after ...Chylothorax is defined as chyle leakage...
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Central Bringing Excellence in Open Access JSM Surgical Oncology and Research Cite this article: Tulelli B, Lemaître P, Farinella E, Devière J, El Nakadi I (2017) Endoscopic Management of Persistent Chylothorax after Esophagectomy for Cancer. JSM Surg Oncol Res 2(2): 1014. *Corresponding author Berenice Tulelli, Department of Digestive Surgery, ULB- Erasme Hospital, 808 Route de Lennik, 1070 Brussels, Belgium, Tel: 0032.025553713; Fax : 0032.025554803; Email: Submitted: 31 March 2017 Accepted: 21 June 2017 Published: 23 June 2017 ISSN: 2578-3688 Copyright © 2017 Tulelli et al. OPEN ACCESS Keywords • Complications after esophagectomy • Chylothorax; Endoscopic management • Transgastric management Case Report Endoscopic Management of Persistent Chylothorax after Esophagectomy for Cancer Berenice Tulelli 1 *, Philippe Lemaître², Eleonora Farinella 1 , Jaques Devière 3 , and Issam El Nakadi 1 1 Department of Digestive Surgery, ULB- Erasme Hospital, Belgium 2 Department of Thoracic Surgery, ULB- Erasme Hospital, Belgium 3 Department of Gastroenterology, ULB- Erasme Hospital, Belgium Abstract Chylothorax is a rare but serious complication after esophageal surgery. Conventional management includes parenteral or modified enteral diet associated with somatostatin or octreotide, or surgical revision. In the face of recurrent and persistent disease, less conventional therapies, such as midodrine administration or lymphatic embolization, have been described. We report a 47 years-old male presenting a recurrent chylothorax after esophagectomy for cancer. Whereas all currently published treatments failed to control lymph oozing, healing was finally achieved by endoscopic ultrasound (EUS) guided intrathoracic transgastric drainage (GITD). ABBREVIATIONS CT scan: Computed Tomography; EUS: Endoscopic Ultrasound; GITD: Guided Intrathoracic Trans-gastric Drainage INTRODUCTION Because of its low incidence, management of post-operative chylothorax is controversial. Facing failure of various approaches, we report the success of EUS-GITD in the case of a mediastinal collection resulting from recurrent post-esophagectomy chylothorax. CASE PRESENTATION A 47 years man was referred to our center for early Barrett’s neoplasia endoscopic evaluation. Esophagogastroscopy showed an ulcer on the Barrett’s mucosa with no lifting sign. Histopathologic examination revealed a superficial adenocarcinoma. Complete workup excluded local extension or distant metastases. After multidisciplinary discussion, the patient underwent an Ivor- Lewis esophagectomy with a 2-field lymphadenectomy and prophylactic thoracic duct ligature. Definitive histopathologic report confirmed a pT1bN0Mx adenocarcinoma. On the 4th postoperative day, the patient developed hypoxemia. A chest CT scan demonstrated a mediastinal effusion, extending left to the esophago-gastric anastomosis, with bilateral pleural effusion and atelectasis. No leak was observed on amidotrizoate swallow. A right-sided chest tube was inserted. High-volume (800 ml/day) fluid drainage with elevated triglyceride dosage (124mg/dl) confirmed chylothorax diagnosis. Initial management consisted in fasting, total parenteral nutrition and octreotide infusion. As no improvement was seen after 2 weeks, the thoracic duct was surgically re-explored after preoperative injection of a fatty dye into the naso-gastric tube. While there was no main duct leakage, some collateral branches showed diffuse effusion and were ligated. Fibrin sealant was also applied. Failure of this procedure led to lymphatic embolization and midodrine administration. As effusion persisted, a left chest tube was placed and urokinase lavages were performed. With time, pleural effusions seemingly resolved. Refeeding and albumin transfusions were needed. However, a chronic posterior mediastinal effusion was still present four months after (Figure 1). A multidisciplinary discussion proposed EUS-guided drainage. Transmural EUS- guided drainage (Olympus GFUM CT 180, Hamburg, Germany) was performed using a cystotome (Cook Endoscopy, Winston Salem, NC) and creating 3 separate drainages through the intra-thoracic stomach into the chylothorax. Orifices were kept opened via placement of 7-French double pigtail stents (Figure 2-3). Complete resorption of the collection ensued and, starting 6 months after drainage, prostheses could be stepwise totally removed. At 18 months, the patient is now in good condition with no recurrence (Figure 4) old. DISCUSSION This case shows that EUS-guided transmural drainage could become part of the armamentarium for management of chylothorax. This is particularly illustrative in the current report where all the classical medical and surgical approaches had failed.
Transcript of Endoscopic Management of Persistent Chylothorax after ...Chylothorax is defined as chyle leakage...
CentralBringing Excellence in Open Access
JSM Surgical Oncology and Research
Cite this article: Tulelli B, Lemaître P, Farinella E, Devière J, El Nakadi I (2017) Endoscopic Management of Persistent Chylothorax after Esophagectomy for Cancer. JSM Surg Oncol Res 2(2): 1014.
*Corresponding authorBerenice Tulelli, Department of Digestive Surgery, ULB- Erasme Hospital, 808 Route de Lennik, 1070 Brussels, Belgium, Tel: 0032.025553713; Fax : 0032.025554803; Email:
Submitted: 31 March 2017
Accepted: 21 June 2017
Published: 23 June 2017
ISSN: 2578-3688
Copyright© 2017 Tulelli et al.
OPEN ACCESS
Keywords•Complications after esophagectomy•Chylothorax; Endoscopic management•Transgastric management
Case Report
Endoscopic Management of Persistent Chylothorax after Esophagectomy for CancerBerenice Tulelli1*, Philippe Lemaître², Eleonora Farinella1, Jaques Devière3, and Issam El Nakadi1
1Department of Digestive Surgery, ULB- Erasme Hospital, Belgium2Department of Thoracic Surgery, ULB- Erasme Hospital, Belgium3Department of Gastroenterology, ULB- Erasme Hospital, Belgium
Abstract
Chylothorax is a rare but serious complication after esophageal surgery. Conventional management includes parenteral or modified enteral diet associated with somatostatin or octreotide, or surgical revision. In the face of recurrent and persistent disease, less conventional therapies, such as midodrine administration or lymphatic embolization, have been described. We report a 47 years-old male presenting a recurrent chylothorax after esophagectomy for cancer. Whereas all currently published treatments failed to control lymph oozing, healing was finally achieved by endoscopic ultrasound (EUS) guided intrathoracic transgastric drainage (GITD).
ABBREVIATIONSCT scan: Computed Tomography; EUS: Endoscopic
Ultrasound; GITD: Guided Intrathoracic Trans-gastric Drainage
INTRODUCTIONBecause of its low incidence, management of post-operative
chylothorax is controversial. Facing failure of various approaches, we report the success of EUS-GITD in the case of a mediastinal collection resulting from recurrent post-esophagectomy chylothorax.
CASE PRESENTATIONA 47 years man was referred to our center for early Barrett’s
neoplasia endoscopic evaluation. Esophagogastroscopy showed an ulcer on the Barrett’s mucosa with no lifting sign. Histopathologic examination revealed a superficial adenocarcinoma. Complete workup excluded local extension or distant metastases. After multidisciplinary discussion, the patient underwent an Ivor-Lewis esophagectomy with a 2-field lymphadenectomy and prophylactic thoracic duct ligature. Definitive histopathologic report confirmed a pT1bN0Mx adenocarcinoma. On the 4th postoperative day, the patient developed hypoxemia. A chest CT scan demonstrated a mediastinal effusion, extending left to the esophago-gastric anastomosis, with bilateral pleural effusion and atelectasis. No leak was observed on amidotrizoate swallow. A right-sided chest tube was inserted. High-volume (800 ml/day) fluid drainage with elevated triglyceride dosage (124mg/dl) confirmed chylothorax diagnosis. Initial management consisted
in fasting, total parenteral nutrition and octreotide infusion. As no improvement was seen after 2 weeks, the thoracic duct was surgically re-explored after preoperative injection of a fatty dye into the naso-gastric tube. While there was no main duct leakage, some collateral branches showed diffuse effusion and were ligated. Fibrin sealant was also applied. Failure of this procedure led to lymphatic embolization and midodrine administration. As effusion persisted, a left chest tube was placed and urokinase lavages were performed. With time, pleural effusions seemingly resolved. Refeeding and albumin transfusions were needed. However, a chronic posterior mediastinal effusion was still present four months after (Figure 1). A multidisciplinary discussion proposed EUS-guided drainage. Transmural EUS-guided drainage (Olympus GFUM CT 180, Hamburg, Germany) was performed using a cystotome (Cook Endoscopy, Winston Salem, NC) and creating 3 separate drainages through the intra-thoracic stomach into the chylothorax. Orifices were kept opened via placement of 7-French double pigtail stents (Figure 2-3). Complete resorption of the collection ensued and, starting 6 months after drainage, prostheses could be stepwise totally removed. At 18 months, the patient is now in good condition with no recurrence (Figure 4) old.
DISCUSSION This case shows that EUS-guided transmural drainage
could become part of the armamentarium for management of chylothorax. This is particularly illustrative in the current report where all the classical medical and surgical approaches had failed.
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and a mortality rate between 0-82% [2], chylothorax remains a rare, but potentially lethal complication following esophagectomy [1]. Triglyceride concentration above 110 mg/dL or presence of chylomicrons in a milky pleural fluid supports the diagnosis. Initial treatment is conservative, based on parenteral or modified enteral diet (medium-chain triglycerols) in association with somatostatin or octreotide. While it is admitted that surgical revision should be performed within seven days from initial intervention, no general consensus on surgical indication or timing exists [3]. Leaks above 13.5ml/kg/day after three days of conservative management suggest treatment failure [2]. Revision should include ligature of all right-sided tissues between column and aorta if the thoracic duct was not initially ligated or its variable anatomy identified by lymphangiography. Pleurodesis may also be performed. Facing persistent leaks, less conventional therapies have been described. These include midodrine (an α-1 adrenergic agonist) administration and pleurovenous or pleuroperitoneal shunts [4]. Okhura and colleagues recently reported the successful combination of etilefrine, a sclerosing agent, with octreotide [5]. Interventional procedures, such as lymphangiography and thoracic duct embolization, should be considered in high flow leaks and poor operative candidates [6].
None of the attempted strategies could halt chyle leakage in our case and the chylothorax evolved to a chronic mediastinal collection. Endoscopic drainage of mediastinal collections has been proposed before, essentially in the context of mediastinal extension of pancreatic pseudocysts [7,8]. A few cases of endoscopic management of lymphocele have been reported but these dealt with delayed collections becoming symptomatic long after surgery [9].
Monk and colleagues reported a 56 year-old patient in whom cystogastrostomy has been performed under CT guidance for a symptomatic post-esophagectomy mediastinal lymphatic cyst [10]. In our case, pigtail stents were placed by EUS-guided transgastric drainage. We believe this approach is safer and more accurate, allowing for precise puncture and hence reduced hemorrhagic risk. This endoscopic strategy could represent an interesting option in the case of postoperative recurring mediastinal chyle collections or even become considered as first-line therapy.
Figure 1 Voluminous posterior mediastinal chronic collection at the 4 months-post operative chest CT scan.
Figure 2 Intra-operative X-ray for double pigtail stents placing.
Figure 3 Trans-gastric chylothorax drainage at chest CT-scan control. Please note collection size decreasing.
Figure 4 18 months-post operative chest CT-scan control, showing complete collection resorption and no recurrence.
Chylothorax is defined as chyle leakage into the pleural space, due to thoracic duct or collateral channels injury. The close relation of the thoracic duct with the esophagus leads to higher rates of chyle leak after esophagectomy, compared to other thoracic procedures [1]. With an incidence ranging from 0.4-4%
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Tulelli B, Lemaître P, Farinella E, Devière J, El Nakadi I (2017) Endoscopic Management of Persistent Chylothorax after Esophagectomy for Cancer. JSM Surg Oncol Res 2(2): 1014.
Cite this article
CONSENTWritten informed consent was obtained from the patient for
publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
REFERENCES1. Shah RD, Luketich JD, Schuchert MJ, Christie NA, Pennathur A,
Landreneau RJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg. 2012; 93: 897-904.
2. Miao L, Zhang Y, Hu H, Longfei Ma, Yihua Shun, Jiaqing Xiang, et al. Incidence and management of chylothorax after esophagectomy. Thorac Cancer. 2015; 6: 354-358.
3. CerfolioRJ. Chylothorax after esophagogastrectomy. Thorac Surg Clin. 2006; 16: 49-52.
4. Liou DZ, Warren H, Maher DP, Soukiasian HJ, Melo N, Salim A, et al. A novel therapeutic for refractory chylothorax. Chest. 2013; 144:1055-1057.
5. Ohkura Y, Ueno M, Iizuka T, Haruta S, Tanaka T, Udagawa H. New
Combined Medical Treatment With Etilefrine and Octreotide for Chylothorax After Esophagectomy. Medicine (Baltimore). 2015; 94: e2214.
6. 6. Lyon S, Mott N, Koukounaras J, Shoobridge J, Hudson PV. Role of interventional radiology in the management of chylothorax: A review of the current management of high output chylothorax. Cardiovasc Intervent Radiol. 2013; 36: 599-607.
7. Mohl W, Moser C, Kramann B, Zeuzem S, Stallmach A. Endoscopic transhiatal drainage of a mediastinal pancreatic pseudocyst. Endoscopy. 2004; 36: 467.
8. Gornals JB, Loras C, Mast R, Botargues JM, Busquets J, Castellote J. Endoscopic ultrasound-guided transesophageal drainage of a mediastinal pancreatic pseudocyst using a novel lumen-apposing metal stent. Endoscopy. 2012; 44: 211-212.
9. Gupta T, Lemmers A, Tan D, Ibrahim M, Le Moine O, Devière J. EUS-guided transmural drainage of postoperative collections. Gastrointest Endosc. 2012; 76: 1259-1265.
10. Monk DN, Nicholson DA, Lee W, Bancewicz J. Case Report Symptomatic mediastinal lymphatic cyst after esophagectomy. Gastrointest Endosc. 1999; 12: 82.
