Resection vs. Ligation vs. Preservation of the Thoracic Duct During Esophagectomy for Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND/OBJECTIVES: The effect of thoracic duct (TD) management-resection, ligation, or preservation-during esophagectomy for cancer remains controversial. This systematic review and meta-analysis aimed to assess the impact of TD management strategies on oncological outcomes and surgical morbidity.

METHODS

A systematic review and meta-analysis were performed following PRISMA reporting guidelines. Searches of OVID, Embase, and Web of Science identified studies comparing thoracic duct resection or TD ligation with TD preservation in esophagectomy for cancer. Outcomes included 5-year overall survival (OS), postoperative morbidity, postoperative chyle leakage, lymph node yield, and length of stay. Random-effects meta-analyses using the Hartung-Knapp-Sidik-Jonkman variance correction were conducted.

RESULTS

A total of 17 studies involving 4200 patients were included. TD resection was associated with a significantly higher lymph node yield (mean difference [MD]: 4, 95% CI: 0 to 8, = 0.043), but also increased risk of chyle leakage (odds ratio [OR]: 2.41, 95% CI: 1.04-5.61, = 0.044). There was no significant improvement in 5-year OS with TD resection compared to TD preservation (hazard ratio [HR]: 0.94, 95% CI: 0.76-1.17, = 0.48). TD ligation showed no significant differences in 5-year OS (HR: 1.15, 95% CI: 0.81-1.63, = 0.33) or morbidity compared to TD preservation. Certainty of evidence was low across outcomes.

CONCLUSIONS

TD resection increases lymph node yield but is associated with higher rates of chyle leakage, without a significantly improved overall survival. TD ligation does not significantly affect oncological or surgical outcomes compared to TD preservation. A higher grade of evidence is needed to determine the definitive oncological and surgical impact of TD management strategies.