Therapeutic strategy for chylous leakage after esophagectomy: focusing on lymphangiography using lipiodol

Conservative treatments are usually attempted for the management of post-esophagectomy chylous leakage. However, surgical intervention may be needed when the chylous leakage cannot be stopped using conservative treatments. For the therapeutic management of refractory chylous leakage, it is important to identify the leakage sites when deciding if surgical intervention is required. Nine patients underwent lymphangiography for the treatment of refractory post-esophagectomy chylous leakage. Radiological findings, the daily outputs of pleural effusion after lymphangiography, and the clinical outcomes after lymphangiography were analyzed in our cases and in a retrospective collection of 24 cases from 1983 to 2015 recorded with precise detail. In the 9 cases directly studied in our center, the median postoperative day of lymphangiography was 15 days. The detection rate of leakage sites after lymphangiography was 89 %. After lymphangiography, daily outputs of pleural effusion less than 500 ml were observed in 5 patients (56 %), all of whom healed conservatively. Daily outputs of more than 500 ml were seen in 4 patients (44 %). Of these patients, 1 patient had leakage from the main trunk and underwent clipping of the thoracic duct. In the remaining 3 patients, the leakages were instead observed in branches or were not observed; the 2 patients who had no anatomical variants were healed by chemical pleurodesis, and the 1 patient who had anatomical variants required surgical intervention. In the analysis of 33 previously reported cases (which included our 9 cases), the therapeutic policy was determined after lymphangiography, and all patients were successfully healed. Early lymphangiography is recommended for patients with refractory post-esophagectomy chylous leakage. Lymphangiography may contribute valuable information in deciding whether surgical intervention is required.