Percutaneous embolization of thoracic duct injury post-esophagectomy should be considered initial treatment for chylothorax before proceeding with open re-exploration

BACKGROUND: Post-esophagectomy patients who develop high-output chylous fistula and chylothorax can be successfully treated with percutaneous ablation thereby avoiding reoperation. METHODS: Five patients with refractory chylous fistula post-esophagectomy were treated with percutaneous embolization. Fistula outputs, evaluation of lymphatic access sites, agents used and additional procedures were analyzed. RESULTS: Successful ablation of the chylous fistula was achieved in 4 of the 5 (80%) patients. Pretreatment chylous output averaged 1,756 mL/day. Cumulative chylous output (resection to ablation) averaged 28 L/patient. A modified technique is detailed, which utilizes direct puncture of groin lymph nodes to facilitate opacification of the thoracic duct. CONCLUSIONS: Percutaneous embolization strategies to treat chylothorax should be considered initial therapy before reoperation and direct ligation. Opacification of the thoracic duct to facilitate direct transhepatic cannulation can be accomplished with direct lymph node cannulation in the groin. Successful ablation of chylothorax following percutaneous embolization is predictable in a high percentage of cases. (C) 2015 Elsevier Inc. All rights reserved