Maruyama Kiyotomi, Shimada Kou, Hamanaka Toshikazu, Sugenoya Shinsuke, Gomi Kuniyuki, Mihara Motohiro, Kajikawa Shoji, Sato Yusuke
Department of Surgery, Suwa Red Cross Hospital, 5-11-50 Kogandoori, Suwa, Nagano, 392-0027, Japan.
Department of Esophageal Surgery, Akita University Hospital, 1-1-1 Hodo, Akita, 010-8543, Japan.
Int J Surg Case Rep. 2017;41:247-250. doi: 10.1016/j.ijscr.2017.10.026. Epub 2017 Oct 24.
We debate whether or not to approach from right thorax for the left chylothorax after esophagectomy.
A 50s-year-old female underwent right-sided thoracoscopic esophagectomy with three-field lymphadenectomy for esophageal carcinoma (type 0-IIa, 3.4×2.2cm, T1bN0M0, Stage IA), followed by reconstruction with esophagogastric anastomosis through the posterior mediastinum. The thoracic duct was excised and ligated. The left thoracic drainage increased to 2115mL/day on the fifth postoperative day. Thoracic duct injury was diagnosed, and surgery was performed on sixth postoperative day. With the patient in a prone position, the thoracic duct was ligated successfully under thoracoscopy in the left thorax. The leakage point was found in the crushed duct by 8.8-mm titanium clips. Then, we performed mass ligation of the thoracic duct with 11-mm titanium clips below the leakage point after careful dissection. The surgery took 58min, with an estimated total blood loss of 0g.
Although thoracic duct is anatomically located on the right side of the descending aorta, we employed a left-sided thoracoscopic approach due to the chylous leakage in the left thorax. With the patient in the prone position, surgeons can easily convert from a left thoracic approach to a right thoracic approach immediately without postural change if the thoracic duct cannot be found in the left thoracic cavity.
This technique is useful and should be considered for patients with left chylothorax.
我们讨论了食管癌切除术后左侧乳糜胸是否应从右胸入路。
一名50多岁的女性接受了右侧胸腔镜食管癌切除术并进行了三野淋巴结清扫术（0-IIa型，3.4×2.2cm，T1bN0M0，IA期），随后通过后纵隔进行食管胃吻合重建。胸导管被切除并结扎。术后第5天左侧胸腔引流量增加至2115mL/天。诊断为胸导管损伤，并于术后第6天进行手术。患者俯卧位，在左胸胸腔镜下成功结扎胸导管。在被8.8毫米钛夹夹闭的导管中发现渗漏点。然后，我们在仔细解剖后，在渗漏点下方用11毫米钛夹对胸导管进行了大块结扎。手术耗时58分钟，估计总失血量为0克。
尽管胸导管在解剖学上位于降主动脉右侧，但由于左胸乳糜漏，我们采用了左侧胸腔镜入路。患者俯卧位时，如果在左胸腔内找不到胸导管，外科医生可以在不改变体位的情况下立即轻松地从左胸入路转换为右胸入路。
该技术是有用的，对于左侧乳糜胸患者应予以考虑。
