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J Thorac Cardiovasc Surg 2001;121:402-403
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Stefano Merigliano, MD, Daniela Molena, MD, Alberto Ruol, MD, Giovanni Zaninotto, MD, Matteo Cagol, MD, Sabrina Scappin, MD, Ermanno Ancona, MD

Padova, Italy

Reply to the Editor:

We read with interest the letter by Patel and Rosin concerning our article on chylothorax complicating esophagectomy for cancer.Go 1

First, we think that the most important point in surgery for esophageal cancer is to prevent postoperative chylothorax. Since 1998 we have routinely ligated the thoracic duct en bloc, with the azygos vein and the lympho-fatty tissue that is located adjacent to the adventitia of the aorta, immediately above the diaphragm during transthoracic esophagectomy. To date, chylothorax has not developed in the last 155 consecutive patients.

Second, we agree that at the present the treatment of choice would be early intervention by a minimally invasive procedure such as thoracoscopic duct ligation. This type of minimally invasive procedure was not used in the patients studied in our article because they were reoperated on before 1997, when open thoracotomy was still the standard procedure in our institution.

Third, we agree that early radiologic intervention with percutaneous catheterization and embolization of the thoracic duct, as proposed by Cope, Salem, and Kaiser,Go 2 is a new appealing procedure. However, this procedure requires an uncommon technical skill because the cisterna chyli or major retroperitoneal lymphatic trunks have to be punctured percutaneously with a fine needle, and the thoracic duct has to be catheterized over a very small guide wire with the use of a 3F catheter to allow embolization of the duct with platinum coils. Furthermore, the procedure has a 45% technical success rate and a reported low clinical success rate: that is, 2 (18%) of 11 cases. In this regard, we underline that the retroperitoneal lymphatic trunks may not be suitable for catheterization in patients operated on for cancer of the esophagus or of the gastric cardia. Such patients should undergo upper abdominal lymph node dissection (including also the celiac artery, hepatic artery, and splenic artery lymph nodes) and dissection of all the retroperitoneal lympho-fatty tissue that is located around the celiac axis and in front of the aorta and diaphragmatic crura.

Finally, as was already discussed in our article, it is very difficult to predict whether a chylous leak will spontaneously close. In our experience the amount of chyle leak by the fifth to seventh days (a leak of more than 1000 mL a day)Go 3 or the ratio of chylous output to body weightGo 4 did not reliably predict the success of continuing conservative treatment.

12/8/111172

doi:10.1067/mtc.2001.111172

References

  1. Merigliano S, Molena D, Ruol A, Zaninotto G, Cagol M, Scappin S, Ancona E. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation. J Thorac Cardiovasc Surg 2000;119:453-7.[Abstract/Free Full Text]
  2. Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J Vasc Interv Radiol 1999;10:1248-54.[Medline]
  3. Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996;112:1361-6.[Abstract/Free Full Text]
  4. Dugue L, Sauvanet A, Farges O, Goharin A, Le Mec J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg 1998;85:1147-9.[Medline]




This Article
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Right arrow Esophagus - cancer

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