Annals of Surgery Open (Sep 2022)
Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers
- Sivesh K. Kamarajah, BMedSci, MBChB, MRCS,
- Manjunath Siddaiah-Subramanya, MD,
- Alessandro Parente, MD,
- Richard P. T. Evans, MRCS, MBChB,
- Ademola Adeyeye, MD,
- Alan Ainsworth, MD,
- Alberto M. L. Takahashi, MD,
- Alex Charalabopoulos, MD,
- Andrew Chang, MD,
- Atila Eroglue, MD,
- Bas Wijnhoven, MD,
- Claire Donohoe, MD,
- Daniela Molena, MD,
- Eider Talavera-Urquijo, MD,
- Flavio Roberto Takeda, MD,
- Gail Darling, MD,
- German Rosero, MD,
- Guillaume Piessen, MD,
- Hans Mahendran, MD,
- Hsu Po Kuei, MD,
- Ines Gockel, MD,
- Ionut Negoi, MD,
- Jacopo Weindelmayer, MD,
- Jari Rasanen, MD,
- Kebebe Bekele, MD,
- Guowei Kim, MD,
- Lieven Depypere, MD,
- Lorenzo Ferri, MD,
- Magnus Nilsson, MD,
- Frederik Klevebro, MD,
- B. Mark Smithers, MD,
- Mark I. van Berge Henegouwen, MD,
- Peter Grimminger, MD,
- Paul M. Schneider, MD,
- C. S. Pramesh, MD,
- Raza Sayyed, MD,
- Richard Babor, MD,
- Shinji Mine, MD,
- Simon Law, MD,
- Suzanne Gisbertz, MD,
- Tim Bright, MD,
- Xavier Benoit D’Journo, MD,
- Donald Low, MD,
- Pritam Singh, PhD FRCS,
- Ewen A Griffiths, MD, FRCS,
- on behalf of the Oesophagogastric Anastomosis Audit collaborative
Affiliations
- Sivesh K. Kamarajah, BMedSci, MBChB, MRCS
- From the * Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- Manjunath Siddaiah-Subramanya, MD
- From the * Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- Alessandro Parente, MD
- § Department of Hepatobiliary Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- Richard P. T. Evans, MRCS, MBChB
- From the * Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- Ademola Adeyeye, MD
- ∥ The Division of Surgical Oncology, Department of Surgery, Afe Babalola University (ABUAD), Nigeria
- Alan Ainsworth, MD
- ¶ Odense University Hospital, Denmark
- Alberto M. L. Takahashi, MD
- # Department of Gastrointestinal Tumors, National Cancer Institute, Mexico City, MX
- Alex Charalabopoulos, MD
- ** Laikon General Hospital, Greece
- Andrew Chang, MD
- †† Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
- Atila Eroglue, MD
- ‡‡ Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey
- Bas Wijnhoven, MD
- §§ Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
- Claire Donohoe, MD
- ∥∥ Department of Surgery, Trinity College Dublin, St James’s Hospital, Dublin, Ireland
- Daniela Molena, MD
- ¶¶ Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Eider Talavera-Urquijo, MD
- ## Department of Surgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Flavio Roberto Takeda, MD
- *** Gastroenterology Department, University of São Paulo, São Paulo, Brazil
- Gail Darling, MD
- ††† Department of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
- German Rosero, MD
- ‡‡‡ Hospital San Ignacio-Universidad Javeriana, Colombia
- Guillaume Piessen, MD
- §§§ CNRS, Inserm, CHU Lille, UMR9020-U1277—CANTHER—Cancer Heterogeneity Plasticity and Resistance to Therapies, University of Lille, Lille, France
- Hans Mahendran, MD
- ∥∥∥ Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Hsu Po Kuei, MD
- ¶¶¶ Taipei Veterans General Hospital, Taiwan
- Ines Gockel, MD
- ### Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Germany
- Ionut Negoi, MD
- **** Emergency Hospital of Bucharest, Romania
- Jacopo Weindelmayer, MD
- †††† General and Upper G.I. Surgery Division, University of Verona, Verona, Italy
- Jari Rasanen, MD
- ‡‡‡‡ Department of Thoracic Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Kebebe Bekele, MD
- §§§§ School of Medicine, Department of Surgery, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
- Guowei Kim, MD
- ∥∥∥∥ National University Hospital, University Surgical Cluster, Singapore
- Lieven Depypere, MD
- ¶¶¶¶ Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Lorenzo Ferri, MD
- #### Department of Thoracic Surgery and Upper Gastrointestinal Surgery, McGill University, Montreal, Canada
- Magnus Nilsson, MD
- ***** Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Frederik Klevebro, MD
- ***** Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- B. Mark Smithers, MD
- ††††† Department of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
- Mark I. van Berge Henegouwen, MD
- ‡‡‡‡‡ Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
- Peter Grimminger, MD
- §§§§§ Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Paul M. Schneider, MD
- ∥∥∥∥∥ Department of Digestive and Oncological Surgery, Hirslanden Medical Center, Zurich, Switzerland
- C. S. Pramesh, MD
- ¶¶¶¶¶ Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
- Raza Sayyed, MD
- ##### Department of Surgical Oncology, Patel Hospital, Karachi, Pakistan
- Richard Babor, MD
- ****** Department of General Surgery, Middlemore Hospital, Auckland, New Zealand
- Shinji Mine, MD
- †††††† Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
- Simon Law, MD
- ‡‡‡‡‡‡ Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
- Suzanne Gisbertz, MD
- ‡‡‡‡‡ Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
- Tim Bright, MD
- §§§§§§ Department of Oesophago-gastric Surgery, Flinders Medical Centre, Australia
- Xavier Benoit D’Journo, MD
- ∥∥∥∥∥∥ Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
- Donald Low, MD
- ¶¶¶¶¶¶ Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington, DC
- Pritam Singh, PhD FRCS
- ###### Regional Oesophago-Gastric Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom.
- Ewen A Griffiths, MD, FRCS
- From the * Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- on behalf of the Oesophagogastric Anastomosis Audit collaborative
- DOI
- https://doi.org/10.1097/AS9.0000000000000192
- Journal volume & issue
-
Vol. 3,
no. 3
p. e192
Abstract
Objective:. This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice. Background:. Chyle leaks following esophagectomy for malignancy are uncommon. Although they are associated with increased morbidity and mortality, diagnosis and management of these patients remain controversial and a challenge globally. Methods:. This was a modified Delphi exercise was delivered to clinicians across the oesophagogastric anastomosis collaborative. A 5-staged iterative process was used to gather consensus on clinical practice, including a scoping systematic review (stage 1), 2 rounds of anonymous electronic voting (stages 2 and 3), data-based analysis (stage 4), and guideline and consensus development (stage 5). Stratified analyses were performed by surgeon specialty and surgeon volume. Results:. In stage 1, the steering committee proposed areas of uncertainty across 5 domains: risk factors, intraoperative techniques, and postoperative management (ie, diagnosis, severity, and treatment). In stages 2 and 3, 275 and 250 respondents respectively participated in online voting. Consensus was achieved on intraoperative thoracic duct ligation, postoperative diagnosis by milky chest drain output and biochemical testing with triglycerides and chylomicrons, assessing severity with volume of chest drain over 24 hours and a step-up approach in the management of chyle leaks. Stratified analyses demonstrated consistent results. In stage 4, data from the Oesophagogastric Anastomosis Audit demonstrated that chyle leaks occurred in 5.4% (122/2247). Increasing chyle leak grades were associated with higher rates of pulmonary complications, return to theater, prolonged length of stay, and 90-day mortality. In stage 5, 41 surgeons developed a set of recommendations in the intraoperative techniques, diagnosis, and management of chyle leaks. Conclusions:. Several areas of consensus were reached surrounding diagnosis and management of chyle leaks following esophagectomy for malignancy. Guidance in clinical practice through adaptation of recommendations from this consensus may help in the prevention of, timely diagnosis, and management of chyle leaks.
