Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers: An International Consensus Statement

Sivesh K Kamarajah, Manjunath Siddaiah-Subramanya, Alessandro Parente, Richard P T Evans, Ademola Adeyeye, Alan Ainsworth, Alberto M L Takahashi, Alex Charalabopoulos, Andrew Chang, Atila Eroglue, Bas Wijnhoven, Claire Donohoe, Daniela Molena, Eider Talavera-Urquijo, Flavio Roberto Takeda, Gail Darling, German Rosero, Guillaume Piessen, Hans Mahendran, Hsu Po KueiInes Gockel, Ionut Negoi, Jacopo Weindelmayer, Jari Rasanen, Kebebe Bekele, Guowei Kim, Lieven Depypere, Lorenzo Ferri, Magnus Nilsson, Frederik Klevebro, B Mark Smithers, Mark I van Berge Henegouwen, Peter Grimminger, Paul M Schneider, C S Pramesh, Raza Sayyed, Richard Babor, Shinji Mine, Simon Law, Suzanne Gisbertz, Tim Bright, Xavier Benoit D'Journo, Donald Low, Pritam Singh, Ewen A Griffiths*

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review

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Abstract

UNLABELLED: 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.

Original languageEnglish
Article numbere192
JournalAnnals of Surgery Open
Volume3
Issue number3
ISSN2691-3593
DOIs
Publication statusPublished - Sept 2022

Bibliographical note

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.

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