1. Post-Esophagectomy Chyle Leak: How to Make a Complex Problem Really Interesting!
Seattle Surgical Society Meeting
February 5, 2016
Mustapha A. El Lakis, MD Kirsten Newhams, MD, MPH Donald E. Low, FACS FRCS(C)
Thoracic Surgery and Thoracic Oncology
Virginia Mason Medical Center

2. Post-Esophagectomy Chyle Leak: How to Make a Complex Problem Really Interesting!
Patient Background
66 Y.O. female
BMI 44
Long history GERD and Barrett’s esophagus
Follow up EGD  Distal esophagus tumor
Bx – moderately diff adenocarcinoma
CT, PET, EDGUS  cT2N1Mx
Treatment
Neoadjuvant chemoradiation
Restaging
Residual tumor cm
Barrett’s cm
Surgery #1
Left thoracoabdominal resection with cervical esophagogastrostomy
Feeding jejunostomy
ICU
1 day
Final path
No residual esophageal cancer
1 of 33 lymph nodes positive pT0N1

3. Post-Esophagectomy Progress
POD 4-8
Output left chest drain L/day
POD 9 Surgery #2
Limited right thoracotomy
Mass ligation thoracic duct at hiatus
POD 10
Chest drains clamped
Continue TPN
POD 1
Initiate J-tube feeds
POD 2
Output left chest drain 400 cc  1 L/24 hr
J-tube feeds held
POD 3
Start TPN
Chest drain output 1.3 L
Triglycerides mod elevated
UGI no leak good emptying

4. POD 11-18 POD 19 POD 20-21 POD 22 Patient stable off O2
POD 6 2nd op pneumo loc fluid
IR CT RX pneumo loculated fluid
POD 11-18
Patient stable off O2
POD 19
Increasing SOB and O2 requirements
CXR left apical pneumothorax and loculated left effusion
IR guided chest drain into left pneumothorax
POD 20-21
Output from left apical chest drain 4-5 L/day
Triglycerides just above normal
POD 22
Lymphangiograph

5. Lymph 11 days following OP 2
lymph thor duct clip
Lymph 11 days following OP 2

6. Post-Esophagectomy Chyle Leak
POD23
Surgery #3
150 cc cream through J-tube starting 2 hours before incision
Laparotomy
Mobilization of gastric conduit
Over sewing of cisterna chyli leak
POD24
Output from left chest drain 40cc
POD 32
Patient discharged
Low fat oral diet
MCT J-tube feeds
Occurs in 1 - 9% of patients following esophageal resection
Chyle leaks originating in the abdomen and draining exclusively into the chest following esophagectomy is rare but surgeons should be aware of this unusual presentation