Impact of Thoracic Duct Resection on Long-Term Survival After Esophagectomy: Individual Patient Data Meta-analysis.

BACKGROUND: Radical esophagectomy, including thoracic duct resection (TDR), has been proposed to improve regional lymphadenectomy and possibly reduce the risk of locoregional recurrence. However, because of its impact on immunoregulation, some authors have expressed concerns about its possible detrimental effect on long-term survival. The purpose of this review was to assess the influence of TDR on long-term survival. PATIENTS AND METHODS: PubMed, MEDLINE, Scopus, and Web of Science databases were searched through 15 March 2024. Overall survival (OS), cancer specific survival (CSS), and disease-free survival (DFS) were primary outcomes. Restricted mean survival time difference (RMSTD), risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (CI) were used as pooled effect size measures. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology was employed to evaluate the certainty of evidence. RESULTS: The analysis included six studies with 5756 patients undergoing transthoracic esophagectomy. TDR was reported in 49.1%. Patients' ages ranged from 27 to 79 years and 86% were males. At 4-year follow-up, the multivariate meta-analysis showed similar results for the comparison noTDR versus TDR in term of OS [- 0.8 months, 95% confidence interval (CI) - 3.1, 1.3], CSS (0.1 months, 95% CI - 0.9, 1.2), and DFS (1.5 months, 95% CI - 2.6, 5.5). TDR was associated with a significantly higher number of harvested mediastinal lymph nodes (SMD 0.57, 95% CI 0.01-1.13) and higher risk of postoperative chylothorax (RR = 1.32; 95% CI 1.04-2.23). Anastomotic leak and pulmonary complications were comparable. CONCLUSIONS: TDR seems not to improve long-term OS, CSS, and DFS regardless of tumor stage. Routine TDR should not be routinely recommended during esophagectomy.

Anesthetic challenges in patients with multicompartmental lymphatic failure after Fontan palliation undergoing transcatheter thoracic duct decompression.

Lymphatic flow abnormalities are central to the development of protein losing enteropathy, plastic bronchitis, ascites and pleural effusions in patients palliated to the Fontan circulation. These complications can occur in isolation or multicompartmental (two or more). The treatment of multicompartmental lymphatic failure aims at improving thoracic duct drainage. Re-routing the innominate vein to the pulmonary venous atrium decompresses the thoracic duct, as atrial pressure is lower than systemic venous pressure in Fontan circulation. Transcatheter thoracic duct decompression is a new minimally invasive procedure that involves placing covered stents from the innominate vein to the atrium. Patients undergoing this procedure require multiple general anesthetics, presenting challenges in managing the sequelae of disordered lymphatic flow superimposed on Fontan physiology. We reviewed the first 20 patients at the Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for transcatheter thoracic duct decompression between March 2018 and February 2023. The patients ranged in age from 3 to 26 years. The majority had failed prior catheter-based lymphatic intervention, including selective embolization of abnormal lympho-intestinal and lympho-bronchial connections to treat lymphatic failure in a single compartment. Fourteen had failure in three lymphatic compartments. Patients were functionally impaired (ASA 3-5) with significant comorbidities. Concurrent with thoracic duct decompression, three patients required fenestration closure for the resultant decrease in oxygen saturation. Ten patients had improvement in symptoms, seven had no changes and three have limited follow up. Five (25%) of these patients were deceased as of January 2024 due to non-lymphatic complications from Fontan failure.

Thoracic Duct Visualization in Esophageal Resection: A Pilot Trial.

INTRODUCTION: Inadvertent thoracic duct injury is common during esophagectomy and may result in postoperative chylothorax. This study's objective was to investigate utility of patent blue injection as a modality for intraoperative thoracic duct visualization. METHODS: A prospective, single-arm, interventional study of patients undergoing minimally invasive esophagectomy was performed. Patients were injected with patent blue dye into both groins prior to thoracic stage of surgery and assessed for duct visualization. Control group was formed by propensity score matching using retrospectively collected data regarding patients who underwent esophagectomy. RESULTS: A total of 25 patients were included in analysis, compared to a control of 50 patients after matching. Thoracic duct was visualized in 60% of patients in the study group (15/25 patients). Significant differences were found between study and control groups (p < 0.05) with regards to median operative time (422 vs. 285 min, respectively), overall complications (16 vs. 34%, respectively), and median postoperative length of stay (13.5 vs. 10 days, respectively). There was a difference in rate of chyle leak between study and control groups; however, this was not significant (0 vs. 12%, respectively, p = 0.17). CONCLUSION: Patent blue injection represents a simple method for thoracic duct visualization during minimally invasive esophagectomy which may improve surgical outcomes.

Evaluation of thoracic duct ligation and unilateral subphrenic pericardiectomy via a left fourth intercostal approach in normal canine cadavers.

OBJECTIVE: To investigate a left-sided fourth intercostal approach to thoracic duct (TD) ligation and unilateral subphrenic pericardiectomy in dogs. STUDY DESIGN: Retrospective computed tomography (CT) review and cadaveric study. ANIMALS: Thirteen dogs with idiopathic chylothorax and 10 canine cadavers. METHODS: A retrospective study of CT lymphangiograms in client-owned dogs with idiopathic chylothorax evaluated location and branching of the TD at the left fourth intercostal space. A cadaveric study evaluated the efficacy of TD ligation at this site. Following methylene blue mesenteric lymph node injection, TDs were identified through a left fourth intercostal thoracotomy, ligated, and sealed. Unilateral subphrenic pericardiectomy was performed through the same incision. Computed tomography scans were performed to determine the success of TD ligation. RESULTS: A review of lymphangiograms revealed a single TD in 10/13 clinical cases at the fourth intercostal space. Three cases had additional branches. Thoracic duct ligation via a left fourth intercostal thoracotomy was successful in nine out of 10 cadavers. A single branch was noted intraoperatively in six out of 10, and two branches were noted in four out of 10 cadavers. All branches were observed on the left side of the esophagus. CONCLUSION: TD ligation at the left fourth intercostal space was successfully performed in 9/10 canine cadavers and appeared feasible in a retrospective review of 10/13 clinical cases. Unilateral subphrenic pericardiectomy can also be performed via this approach. CLINICAL SIGNIFICANCE: Fewer thoracic duct branches at this location in comparison with the standard caudal location may simplify TD ligation. If elected, unilateral subphrenic pericardiectomy can be performed through the same incision. Further investigation in clinical patients is warranted.

Thoracoscopic Management of Chylothorax by Application of a Fibrin Sealant Patch.

Thoracic duct ligation is a demanding procedure when the chyle leak and/or the duct itself are not identified. This report describes a new procedure using thoracoscopic closure of the chyle leak by application of a fibrin sealant patch. This strategy was successfully applied for closing (i) a small fistula due to a postoperative lesion of the lymphatic tributary vessels in one case, and (ii) a large fistula due to idiopathic rupture of the thoracic duct in another case.

Outcome of video-assisted thoracoscopic treatment of idiopathic chylothorax in 15 cats.

OBJECTIVE: To evaluate the outcomes and complications of video-assisted thoracoscopic (VATS) treatment of chylothorax in cats. STUDY DESIGN: Multi-institutional retrospective study. ANIMALS: Fifteen client-owned cats. METHODS: The medical records of cats undergoing thoracoscopic thoracic duct ligation (TDL) for treatment of idiopathic chylothorax were reviewed. Cats undergoing additional procedures including thoracoscopic pericardectomy and/or laparoscopic cisterna chyli ablation (CCA)_were included. Follow up was obtained through communication with the referring veterinarian or owner. RESULTS: All cats underwent thoracoscopic TDL. Thirteen cats underwent simultaneous pericardectomy and two cats underwent laparoscopic CCA without pericardectomy. Conversion from a thoracoscopic to open approach was necessary in 2/15 (13%) of thoracic duct ligations and 1/11 (9%) of pericardectomies. The most common postoperative complication was persistent pleural effusion in five cats (33%). Four of 15 cats (27%) died or were euthanized prior to hospital discharge following surgery. Recurrence of effusion occurred in 1/7 (14%) of cats that sustained resolution of the effusion at the time of surgery with a median follow up of 8 months. The overall mortality attributed to chylothorax was 47%. CONCLUSION: Thoracoscopic treatment of idiopathic chylothorax resulted in a low incidence of intraoperative complications or conversion in the study population; however, mortality related to feline idiopathic chylothorax remained high. CLINICAL SIGNIFICANCE: While VATS treatment of idiopathic chylothorax is technically feasible, further consideration of the underlying pathology and current treatment algorithm is needed to improve outcomes as this remains a frustrating disease to treat in the feline population.

Prognosis of Patients with Esophageal Carcinoma After Routine Thoracic Duct Resection: A Propensity-matched Analysis of 12,237 Patients Based on the Comprehensive Registry of Esophageal Cancer in Japan.

OBJECTIVE: To clarify whether routine thoracic duct (TD) resection improves the prognosis of patients with esophageal cancer after radical esophagectomy. SUMMARY OF BACKGROUND DATA: Although TD resection can cause nutritional disadvantage and immune suppression, it has been performed for the resection of surrounding lymph nodes. METHODS: We analyzed 12,237 patients from the Comprehensive Registry of Esophageal Cancer in Japan who underwent esophagectomy between 2007 and 2012. TD resection and preservation groups were compared in terms of prognosis, perioperative outcomes, and initial recurrent patterns using strict propensity score matching. Particularly, the year of esophagectomy and history of primary cancer of other organs were added as covariates. RESULTS: After propensity score matching, 1638 c-Stage I-IV patients participated in each group. The 5 year overall survival and cause-specific survival rates were 57.5% and 65.6% in the TD-resected group and 55.2% and 63.4% in the TD-preserved group, respectively, without significant differences. The TD-resected group had significantly more retrieved mediastinal nodes (30 vs 21, P < 0.0001) and significantly fewer lymph node recurrence (376 vs 450, P = 0.0029) compared with the TD-preserved group. However, the total number of distant metastatic organs was significantly greater in TD-resected group than in the TD-preserved group (499 vs 421, P = 0.0024). CONCLUSIONS: TD resection did not improve survival in patients with esoph-ageal cancer. Despite having retrieved more lymph nodes, TD resection caused distant metastases in more organs compared to TD preservation. Hence, prophylactic TD resection should not be recommended in patients with esophageal cancer.

Endovascular Lymphatic Decompression via Thoracic Duct Stent Placement for Refractory Ascites in Patients with Cirrhosis: A Pilot Study.

PURPOSE: To evaluate the technical and clinical success of endovascular lymphatic decompression via thoracic duct (TD) stent placement in patients with cirrhosis with refractory ascites. MATERIALS AND METHODS: Nine patients (6 men and 3 women; median age, 66 [interquartile range {IQR}, 65-68] years; range, 62-78 years) who underwent TD stent placement for refractory ascites with contraindications for liver transplantation and transjugular intrahepatic portosystemic shunt creation were included in this retrospective study. TD stent placement was performed under local anesthesia using retrograde access from the venous system. Self-expanding stents from 5 to 8 mm in diameter were used and extended into the subclavian vein by approximately 1 cm. Technical (correct positioning of the stent) and clinical success (no more requirement of paracentesis) were evaluated. In addition, the safety of the procedure and TD pressure evolution were evaluated. RESULTS: The technical success rate was 100%, and 3 (33%) patients reported clinical success. Five (56%) patients reported 7 minor adverse events (Grade I), among which 2 TD perforations were induced by stent angioplasty, with no clinical manifestation or treatment required. The median TD pressure decreased from 19 mm Hg (IQR, 11-24 mm Hg) at the beginning of the procedure to 6 mm Hg (IQR, 5-11 mm Hg) after TD stent placement. The median survival time after the procedure was 7.1 months. CONCLUSIONS: Endovascular lymphatic decompression via TD stent placement is feasible and safe and was effective on ascites in some patients with cirrhosis with refractory ascites.

Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery.

PURPOSE: Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye. METHODS: Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5 mg ICG dye (total 5 mg) under sonographic guidance during anesthesia induction. Stryker's 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina. RESULTS: In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60 min post-injection; range 30-330). No patient experienced any chyle leak within 30 days post-surgery and no adverse reactions to ICG was evident. CONCLUSIONS: Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.

The impact of thoracic duct resection on the long-term body composition of patients who underwent esophagectomy for esophageal cancer and survived without recurrence.

BACKGROUND: We have reported the possible benefits of radical esophagectomy with thoracic duct (TD) resection in elective esophageal cancer surgery. However, the effect of TD resection on the long-term nutrition status remains unclear. METHODS: Patients who underwent esophagectomy at Keio University between January 2006 and December 2018 were included, and those who had no recurrence for more than three years were evaluated. Changes in each body composition (muscle mass and body fat) were comparatively assessed between those who underwent TD resection or not, before and at, one, three and five years after surgery. Computed tomography images were analyzed on postoperative year 1, 3 and 5. RESULTS: This study included 217 patients categorized in the TD-resected (TD-R) (156 patients) and TD-preserved (TD-P) (61 patients) groups. The loss of muscle mass was comparable between the groups. On the other hand, the loss of adipose tissues was significantly greater in the TD-R group than in the TD-P group at one and three years after surgery, while there was no statistical difference five years after surgery. Additionally, among patients with cT1N0M0 disease in whom survival advantage of TD resection has been reported previously, the loss of muscle mass did not differ between each group. CONCLUSIONS: The change of muscle mass between the two groups was comparable. Although body fat mass was reduced by TD resection, it eventually recovered in the long term. In patients with esophageal cancer, TD resection may be acceptable without significant impact on body composition in the long term.

Clinical implications of chyle leakage following esophagectomy.

The clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy. This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017-2020. Routinely, the thoracic duct was resected en bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/L, according to the Esophagectomy Complications Consensus Group (ECCG) classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay. Chyle leakage was present in 43/314 patients (14%), of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental nutrition (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during readmission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI:0.46-0.76) and 3 days longer hospital stay (BCa 95%CI:0.07-0.36), independently of the presence of other complications. Chyle leakage is a relatively frequent complication following esophagectomy. Postoperative chyle leakage was associated with a significant longer duration of thoracic drainage and hospital admission. Nonsurgical treatment was successful in all patients with chyle leakage.

Oncological and physiological impact of thoracic duct resection in esophageal cancer.

Despite advances in multidisciplinary treatment, esophagectomy remains the main curative treatment for esophageal cancer. The advantages and disadvantages of thoracic duct (TD) resection have been controversial for decades. We have herein reviewed relevant published literature regarding 'thoracic duct,' 'esophageal cancer,' and 'esophagectomy' describing the anatomy and function of the TD, and incidence of thoracic duct lymph nodes (TDLN) and TDLN metastases, as well as the oncological and physiological effects of TD resection. The presence of lymph nodes around the TD, referred to as TDLN, has been reported previously. The delineation of TDLNs is clearly defined by a thin fascial structure covering the TD and the surrounding adipose tissue. Previous studies have examined the number of TDLNs and the percentage of patients with TDLN metastasis and revealed that each patient had approximately two TDLNs. The percentage of patients with TDLN metastasis was reported to be 6-15%. Several studies have been conducted to compare the survival after TD resection with that after TD preservation. However, no consensus has been reached because all studies were retrospective, precluding firm conclusions. Although the issue of whether the risk of postoperative complications is affected by TD resection is still unclear, resecting the TD has been shown to have a long-term impact on nutritional status after surgery. In summary, TDLNs are quite common and present in most patients, while metastasis in the TDLNs occurs in a minority. However, the oncological value of TD resection in esophageal cancer surgery remains controversial due to varying findings and methodological limitations of previous comparative studies. Considering the potential but unproven oncological benefits and possible physiological drawbacks of TD resection, including postoperative fluid retention and disadvantages in the long-term nutritional outcome, clinical stage, and nutritional status should be considered before deciding whether to perform TD resection or not.

Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy.

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40 mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax.

Near-infrared fluorescence imaging of thoracic duct in minimally invasive esophagectomy.

Chylothorax is a serious complication after esophagectomy and there are unmet needs for new intraoperative navigation tools to reduce its incidence. The aim of this study is to explore the feasibility and effectiveness of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify thoracic ducts (TDs) and chyle leakage during video-assisted thoracoscopic esophagectomy. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy (MIE) for esophageal cancer in this prospective, open-label, single-arm clinical trial. ICG was injected into the right inguinal region before operations, after which TD anatomy and potential chyle leakage were checked under the near-infrared fluorescence intraoperatively. In 38 of 41 patients (92.7%) using NIR-FI, TDs were visible in high contrast. The mean signal-to-background ratio (SBR) value of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligations were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs as well as determine the source of chyle leakage, which might help reduce TD injury and direct selective TD ligation. It could be a promising navigation tool to reduce the incidence of chylothorax after minimally invasive esophagectomy.

Delayed non-selective contrast-enhanced CT can reveal spontaneous contrast enhancement of the lymphatic system in cats.

The authors incidentally observed that, on delayed postcontrast CT studies, feline patients could show increased attenuation of the lymphatic system. The aim of the present study was to evaluate if the lymphatic system of feline patients undergoing intravenous administration of contrast medium might consistently enhance on delayed postcontrast CT studies. Feline patients that underwent CT examination for variable diagnostic purposes were included in this multicentric observational descriptive study. A 10-min delayed postcontrast whole-body CT series was obtained for all cats enrolled and the following anatomic structures were systematically assessed: mesenteric lymphatic vessels, hepatic lymphatic vessels, cisterna chyli, thoracic duct, and anastomosis of the thoracic duct with the systemic venous system. A total of 47 cats were included in the study. The mesenteric lymphatic vessels showed enhancement in the selected series in 39 of 47 (83%) patients and the hepatic lymphatic vessels in 38 of 47 (81%) patients. The cisterna chyli, thoracic duct, and the point of anastomosis of the thoracic duct with the systemic venous circulation were enhanced in 43 (91%), 39 (83%), and 31 of 47 (66%) cats, respectively. This study confirms the initial observation. The mesenteric and hepatic lymphatic system, the cisterna chyli, the thoracic duct, and its anastomosis with the systemic venous circulation of feline patients undergoing intravenous administration of iodinated contrast medium can show spontaneous contrast enhancement in non-selective 10-min delayed contrast-enhanced CT series.

Therapeutic effect of lymphography in the postoperative chylothorax - case reports and literature review.

Postoperative chylothorax is a well-known rare complication of thoracic surgery. It is a serious complication that is fatal in cases of inadequate treatment. The authors present 2 cases of postoperative chylothorax that were successfully treated by performing pedal and/or intranodal lymphography. In one case, the patient underwent lymphography after previous unsuccessful surgical ligation of the thoracic duct. The presented case reports describe therapeutic importance of conventional lymphography as a minimally invasive treatment of the postoperative chylothorax.

Skeletonizing En Bloc Esophagectomy Revisited: Oncologic Outcome in Association with the Presence of Thoracic Duct Lymph Nodes.

BACKGROUND: Skeletonizing en bloc esophagectomy (SEBE) involves the removal of the esophagus en bloc with locoregional soft tissues and lymph nodes, including the thoracic duct (TD); however, its oncologic benefits remain unclear. We evaluated the impact of SEBE on oncologic outcomes in patients with esophageal squamous cell carcinoma. METHODS: Patients undergoing McKeown esophagectomy without neoadjuvant therapy between 2013 and 2019 were evaluated. Outcomes after SEBE were compared with those after conventional esophagectomy (CE) using propensity score-matched analysis. RESULTS: Overall, 232 patients were identified, including 133 patients with SEBE and 99 patients with CE. Lymph node metastasis along the TD was identified in 7.5% (10/133) of the SEBE group, and the incidence was closely related with the tumor invasion depth (2.2% in pT1 and 19.0% in pT2-3). Based on the propensity score, 180 patients (90 pairs) were analyzed. Tumor recurrence was identified in 24.4% and 12.2% of CE and SEBE cases, respectively (p = 0.036). The observed difference was due to the higher incidence of locoregional recurrence in CE (10.5% vs. 2.2%; p = 0.024), while the incidence of systemic recurrence was similar (18.6% vs. 12.2%; p = 0.240). The 5-year disease-free survival rate was 83.6% and 62.4% in the SEBE and CE groups, respectively (p = 0.022). Multivariate analysis revealed that SEBE could significantly reduce the risk of recurrence or death in patients with pT2-3 tumors (hazard ratio 0.173, 95% confidence interval 0.048-0.628; p = 0.008). CONCLUSIONS: SEBE could identify and eradicate lymphatic metastasis along the TD and positively impact disease-free survival, particularly in patients with pT2-3 tumors.

Pragmatic role of noncontrast magnetic resonance lymphangiography in postoperative chylothorax or cervical chylous leakage as a diagnostic and preprocedural planning tool.

OBJECTIVES: To define the roles of noncontrast magnetic resonance lymphangiography (MRL) in the management of postoperative chylothorax or cervical chylous leakage. METHODS: A total of 50 consecutive patients underwent noncontrast MRL, intranodal lymphangiography, and thoracic duct embolization between May 2016 and April 2020. Their mean age was 62.6 years ± 10.3 (SD) years, and 35 of the participants were men. Conventional lymphangiographic images were sufficient in quality as a reference for the evaluation of diagnostic accuracy of leakage and location in 35 patients (70%) and for evaluation of anatomic details of the thoracic duct and jugulovenous junction in 34 patients (68%). RESULTS: MRL showed that the sensitivity, specificity, and positive and negative predictive values for leakage detection were 100%, 97.1%, 100%, and 100%, respectively, and the concordance rate was 97.14% (95% confidence interval [CI], 85.08-99.93%; p < .001). Leakage location was concordant between MRL and conventional lymphangiography in 27 patients (77.1%, 27/35). Regarding anatomical details of the thoracic duct, variation of the thoracic duct was missed in 11.7% of patients (4/34). The jugulovenous junction was observed in 91.1% (31/34), and its opening into the central vein was depicted in 76.4% (26/34). The concordance rate was between 76.47 and 91.18. CONCLUSIONS: Noncontrast MRL has a high sensitivity for the detection of postoperative thoracic and cervical chylous leakage but is suboptimal for the localization of the leak and depiction of anatomical details of the thoracic duct. This method is worthy of consideration as either a decision-making or planning tool for subsequent interventions. KEY POINTS: • Noncontrast MRL provides limited resolution images of CLS but has a high sensitivity for the detection of postoperative chylous leakage in the thoracic and neck regions. • Noncontrast MRL is suboptimal for depicting anatomic details in the thoracic duct and jugulovenous junction but can play a role as a decision-making and a planning tool for subsequent lymphatic interventions.

Prophylactic thoracic duct obliteration and resection during esophagectomy: What is the impact on perioperative risks and long-term survival? A systematic review and meta-analysis.

There is no agreement whether prophylactic thoracic duct ligation (TDL), with or without resection, during esophagectomy for patients with cancer is beneficial. The effects of these procedures on postoperative complications and overall survival remain unclear. This systematic review included 16 articles. TDL did not influence short- and long-term outcomes. However, thoracic duct resection increased postoperative chylothorax and overall complications, with no improvement in survival.

Percutaneous Radiofrequency Ablation to Occlude the Thoracic Duct: Preclinical Studies in Swine for a Potential Alternative to Embolization.

PURPOSE: To investigate the feasibility of percutaneous radiofrequency (RF) ablation to occlude the thoracic duct (TD) in a swine model with imaging and histologic correlation. MATERIALS AND METHODS: Six swine underwent TD RF ablation. Two terminal (4 hours, 1 open and 1 percutaneous) and 4 survival (30 days, all percutaneous) studies were performed. Two 20-gauge needles were placed adjacent to the TD under direct visualization after right thoracotomy or under fluoroscopic guidance using a percutaneous transabdominal approach after intranodal lymphangiography. RF electrodes were advanced through the needles, and ablation was performed at 90°C for 90 seconds. Lymphangiography was performed, and the TD and adjacent structures were resected and examined microscopically at the end of each study period. RESULTS: Four of 6 subjects survived the planned study period and underwent follow-up lymphangiography. Two subjects in the survival group were euthanized early-1 after developing an acute chylothorax and 1 because of gastric volvulus 14 days after ablation. Occlusion of the targeted TD segment was noted on lymphangiography in 3 of the 4 remaining subjects (2 acute and 1 survival). Histology 4 hours after RF ablation demonstrated necrosis of the TD wall and hemorrhage within the lumen. Histology at 14 and 30 days revealed fibrosis with hemosiderin-laden macrophages replacing the ablated TD. Collagen degeneration within the aortic wall involving a maximum of 60% thickness was noted in 5 of the 6 subjects. CONCLUSIONS: Percutaneous RF ablation can achieve short-segment TD occlusion. Further study is needed to improve safety and demonstrate clinical efficacy in treating TD leaks.