Thoracic Duct Embolization for Delayed Chyle Leak After Lewis-Tanner Esophagectomy

Patient: Male, 54-year-old Final Diagnosis: Chyle leak Symptoms: Abdominal pain Medication:— Clinical Procedure: — Specialty: Radiology • Surgery OBJECTIVE: Unusual or unexpected effect of treatment BACKGROUND: Radical esophagectomy for cancer is a potentially curative treatment that requires two/three-field lymphadenectomy. Serious complications can occur, including chyle leak (CL). CL has an incidence rate of 1–9% and is associated with a higher rate of postsurgical morbidity and mortality. It usually occurs in the early postoperative period; delayed CL is less common and is thought to be due to an occult leak or late diagnosis. CASE REPORT: A 54-year-old man with adenocarcinoma of the esophagus underwent Lewis-Tanner esophagectomy after neoadjuvant chemotherapy with FLOT. During en bloc lymphadenectomy, the main thoracic duct was identified, clipped, and divided. The postoperative course was uneventful. One month after hospital discharge, he was readmitted with severe abdominal, scrotal, and lower-limb edema. A chest-abdomen CT scan revealed massive pleural effusion with left shift and compression of the mediastinum. The patient was initially treated with fasting and fat-free total parenteral nutrition, and the drain output was 2800–3000 mL/dL. Lymphoscintigraphy with ethiodized oil eventually revealed a thoracic duct leak, and lymphatic embolization was successfully performed with a 4-mm metallic spiral and glue. Drain output dramatically reduced, and after 11 days the thoracic drain was removed and the patient was safely discharged. CONCLUSIONS: Thoracic duct embolization seems be an effective therapy in treating high-output (>1000 mL/dL) CL that has occurred more than 2 weeks after esophagectomy. It can be considered as a first-line treatment due to its simplicity and effectiveness.