Outcome of a Step-Up Treatment Strategy for Chyle Leakage After Esophagectomy
Weijs, Teun J; Ruurda, Jelle P; Broekhuizen, Maria E; Bracco Gartner, Tom C L; van Hillegersberg, Richard
(2017) Annals of Thoracic Surgery, volume 104, issue 2, pp. 477 - 484
(Article)
Abstract
Background: Thoracic chyle leakage is a major complication of esophagectomy. In this study our treatment strategy for chyle leakage was evaluated and its risk factors were identified. Methods: According to the Esophagectomy Complications Consensus Group recommendations, chyle leakage was classified as follows: I, enteric dietary modifications; II, total parenteral nutrition
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(TPN); and III, interventional or surgical therapy. It was graded as A, less than 1,000 mL per day; or B, more than 1,000 mL per day. In our protocol, chyle leakage less than 500 mL per day was treated with a low-fat diet; more than 1,000 mL per day, with TPN, and 500 to 1,000 mL per day, with a low-fat diet or TPN depending on whether the chyle leakage was increasing or decreasing at diagnosis and the clinical condition. Surgery was reserved for refractory leakages. Results: In total 371 patients were included. Chyle leakage incidence was 21%, consisting of 51% grade A and 49% grade B leakage. Chyle leakage severity was associated with length of stay (grade A, median 17 days versus B, 25 days; p = 0.006). Independent risk factors were a transthoracic approach (odds ratio 4.8, p = 0.002), neoadjuvant chemoradiotherapy (odds ratio 2.6, p = 0.002), and preoperative body mass index (exp(B) 0.92, p = 0.031). Treatment consisted of low-fat diet in 53%, TPN in 37%, and surgery in 10% of the patients. Low-fat diet and TPN successfully treated 87% of chyle leaks. Chyle leakages treated by TPN first were significantly more severe compared with those treated first by low-fat diet, and were significantly associated with electrolyte deficiencies, increased complication severity, and length of stay, but not with 90-day mortality. Conclusions: A step-up treatment strategy, starting with dietary modifications, solved nearly 90% of chyle leaks conservatively. A minority of chyle leaks required surgery.
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Keywords: Aged, Chyle, Drainage, Enteral Nutrition, Esophageal Neoplasms, Esophagectomy, Female, Humans, Incidence, Male, Middle Aged, Netherlands, Pleural Effusion, Postoperative Complications, Practice Guidelines as Topic, Reoperation, Retrospective Studies, Risk Factors, Surgery, Pulmonary and Respiratory Medicine, Cardiology and Cardiovascular Medicine, Journal Article
ISSN: 0003-4975
Publisher: Elsevier USA
Note: Publisher Copyright: © 2017 The Society of Thoracic Surgeons Copyright: Copyright 2018 Elsevier B.V., All rights reserved.
(Peer reviewed)