Kuroda Akihiro, Yajima Sho, Urabe Masayuki, Yoshimura Shuntaro, Ri Motonari, Yagi Koichi, Seto Yasuyuki
Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Gastrointestinal Surgery Division, Department of Surgery, Japanese Red Cross Omori Hospital, Tokyo, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.24-0129. Epub 2025 Apr 25.
Chylothorax following esophagectomy is a relatively rare but significant complication, with incidences ranging from 1.1% to 3.8%. It typically arises from damage to the thoracic duct or associated lymphatic vessels during extensive lymph node dissection and thoracic surgery. Initial management usually relies on conservative approaches such as dietary modifications, drainage, and pharmacotherapy. If these methods are ineffective, surgical intervention becomes necessary. However, standardized guidelines for the optimal management of thoracic duct injuries are as yet lacking, with decisions made on a case-by-case basis. We describe a case of chylothorax following esophagectomy where lymphangiography played a crucial role in guiding the surgical approach.
We report the clinical course of a 72-year-old male who developed chylothorax following esophagectomy for recurrent esophageal cancer. Despite initial conservative management, including octreotide and total parenteral nutrition, the patient's condition required further intervention. Lymphangiography performed on postoperative day (POD)14 revealed a rare anatomical variation of the thoracic duct, leading to successful surgical ligation through a right cervical approach. The patient's postoperative course was complicated by mediastinal fluid accumulation and resultant cardiac tamponade, necessitating emergency mediastinal drainage. Following the targeted surgical intervention, the drainage volume decreased, and the patient gradually resumed oral intake after swallowing function training. He was discharged on POD118.
Thoracic duct injury after esophagectomy is challenging, especially with anatomical variations. Lymphangiography enables precise localization, guides surgery, and improves outcomes in chylothorax patients. The literature confirms that its early use reduces hospital stays and complications. Tumor invasion or inflammation at or beyond T3 may increase surgical complexity and injury risk. Given its diagnostic and therapeutic benefits, lymphangiography should be integrated into the standard protocols for chylothorax, especially in cases in where conservative treatment fails or anatomical variations are suspected.
食管癌切除术后乳糜胸是一种相对罕见但严重的并发症，发生率在1.1%至3.8%之间。它通常是在广泛的淋巴结清扫和胸外科手术过程中，胸导管或相关淋巴管受损所致。初始治疗通常依赖于保守方法，如饮食调整、引流和药物治疗。如果这些方法无效，则需要进行手术干预。然而，目前仍缺乏针对胸导管损伤最佳治疗的标准化指南，治疗决策需逐案制定。我们描述了一例食管癌切除术后乳糜胸病例，其中淋巴管造影在指导手术方法方面发挥了关键作用。
我们报告了一名72岁男性的临床病程，该患者因复发性食管癌行食管癌切除术后发生乳糜胸。尽管最初采取了包括奥曲肽和全胃肠外营养在内的保守治疗，但患者的病情仍需要进一步干预。术后第14天进行的淋巴管造影显示胸导管存在罕见的解剖变异，通过右颈入路成功进行了手术结扎。患者术后病程因纵隔积液及由此导致的心包填塞而复杂化，需要紧急纵隔引流。经过有针对性的手术干预，引流量减少，患者在吞咽功能训练后逐渐恢复经口进食。他于术后第118天出院。
食管癌切除术后胸导管损伤具有挑战性，尤其是存在解剖变异时。淋巴管造影能够精确定位，指导手术，并改善乳糜胸患者的治疗效果。文献证实，早期使用淋巴管造影可缩短住院时间并减少并发症。肿瘤侵犯至T3及以上或存在炎症可能增加手术复杂性和损伤风险。鉴于其诊断和治疗益处，淋巴管造影应纳入乳糜胸的标准治疗方案，尤其是在保守治疗失败或怀疑存在解剖变异的病例中。
