Transhiatal bilateral thoracic duct ligation for duplicated thoracic duct injury after esophagectomy: a case report

Abstract

Background The treatment of duplicated thoracic ducts (TDs) injury after esophagectomy generally requires a bilateral transthoracic approach. We present the cases of two patients with postoperative chylothorax who underwent transhiatal bilateral TD ligation for duplicated TDs. Case presentation Two patients diagnosed with chylothorax after esophagectomy performed for thoracic esophageal cancer underwent transhiatal TD ligation. Although supradiaphragmatic mass ligation was performed on the fat tissue of the right side of the aorta containing the TD, chyle leakage persisted. To tackle this, the fat tissue of the left side of the aorta was ligated, after which the chyle leakage stopped. Conclusion Compared to the conventional transthoracic approach, the transhiatal approach enables the ligation of both left- and right-sided TD in a single surgical operation, without the need to change the patient’s posture. This approach may be appropriate for the treatment of chylothorax after esophagectomy, considering the possibility of duplicated TDs.

Laparoscopic transhiatal en‐mass thoracic duct ligation for persistent bilateral spontaneous Chylothorax: A case report

“…The evidence-based efficacy of the transhiatal approach cannot be stated due to a handful of studies limited to case series or reports. [6][7][8] However, our experience and these studies have established the feasibility and safety of the laparoscopic transhiatal approach. So it remains a valuable option in patients not suitable for thoracoscopy due to various reasons.…”

“…The early TDL in the supradiaphragmatic region increases efficacy as injuries to the thoracic duct are usually higher. 8 The limitation of our case study was that the anatomy of the thoracic duct before surgery was not studied due to a lack of lymphangiography. As the thoracic duct is known for frequent variation, 9 the chance of failure, in the case of anomalous thoracic duct, was there.…”

“…So we chose en‐mass ligation to ensure incorporation of the thoracic duct by clipping all the soft tissues. The evidence‐based efficacy of the transhiatal approach cannot be stated due to a handful of studies limited to case series or reports 6–8 . However, our experience and these studies have established the feasibility and safety of the laparoscopic transhiatal approach.…”

“…This approach has the advantage of the ability for bilateral ligation of the thoracic duct, if required, in case of variant anomaly of the thoracic duct as well. 8 The laparoscopic transhiatal approach has the advantage of magnified vision, minimizing the impact on cardiopulmonary dynamics due to one‐lung ventilation or prone position requirement in thoracoscopy. Furthermore, the morbidity and pain associated with chest tubes after thoracoscopy can be avoided.…”

“…The early TDL in the supradiaphragmatic region increases efficacy as injuries to the thoracic duct are usually higher. 8 …”