We have reported two cases of chylothorax after radical esophagectomy who underwent surgical intervention using a transhiatal approach, Both patients were successfully treated via supradiaphragmatic TD ligation on both sides of the descending aorta in a single surgical site during a single-stage surgery for duplicated TDs. Transhiatal TD ligation did not require one-lung ventilation and could be performed without direct visualization of the injured intrathoracic area. To our knowledge, this is the first report of bilateral TD ligation performed with the transhiatal approach for chylothorax after esophagectomy.
Left-sided TD has been previously described. In 1953, Adachi et al. performed 261 autopsies and described nine types of anatomical variation [17]. Types I, II, and III involve bilateral TDs; types IV, V, and VI involve right-sided TD; and types VII, VIII, and IX involve left-sided TD. Furthermore, types I, IV, and VII involve bilateral outflow; types II, V, and VIII involve right outflow; and types III, VI, and IX involve left outflow. None of the autopsies revealed type I, II, VII, and VIII TDs. Therefore, in clinical practice, patients with left-sided TD are classified as Type III or IX, and the frequency of left-sided TD is as high as 7.8–10.6% [8,9,10]. Transthoracic ligation of the TD is the standard surgical procedure for post-esophagectomy chylothorax; therefore, bilateral TDs are commonly treated with a bilateral transthoracic approach [3, 11,12,13,14]. This approach requires changing the patients’ posture during surgery, extending the surgical duration. Conversely, the transhiatal approach allows the ligation of right and left-sided TDs in a single surgical site and during a single-stage surgery in the supine position.
Transhiatal TD ligation in the supradiaphragmatic space was first described by Miyamura et al. [15]. Suzuki et al. later reported it as an effective surgical treatment for chylothorax [16]. The lower posterior mediastinum was released for re-exploration through phrenotomy. The left-sided TD could be ligated using a procedure similar to that used for the right side in a single surgical site. The ability to ligate bilateral TDs through a hiatal approach is the major advantage of this approach in treating TD injury. Other studies have described that the retraction of the conduit and adhesiolysis are not difficult because this space has typically been dissected during the initial surgery and is friable [18]. Even in our patients, the surgical site was easily exposed without adhesiolysis.
Another advantage of the transhiatal approach is the minimal cardiopulmonary invasiveness in which one-lung ventilation is avoided [16, 19, 20]. While patients with postoperative chylothorax have undergone major thoracic surgery and are often unsuitable for a transthoracic approach because of debilitation, the transhiatal approach minimizes the impact on circulatory and respiratory dynamics. Moreover, the identification and treatment of the actual site of the injured TD are not necessary with this approach [15, 16, 21]. The TD tends to be injured around the tracheal bifurcation during esophagectomy; however, due to the preceding surgery, the actual site of injury is difficult to detect intraoperatively [20, 22]. In the transhiatal approach, the TD is ligated at the supradiaphragmatic space (the afferent side of the injured lesion); thus, the lymph flow to the damaged area can be blocked [4, 15, 16]. Owing to these advantages, the transhiatal procedure is useful for patients who are ineligible for a transthoracic approach; for example, those who have undergone pulmonary surgery and esophagectomy.
The treatment for chylothorax remains controversial and evidence for the optimal management is lacking because of its low incidence. Radiological procedures using imaging devices, such as percutaneous lymphangiography, are superior in terms of reducing mortality; however, their effectiveness is presumably lower than that of surgery [7]. Recently, the transhiatal laparoscopic approach was reported as a safe and fast procedure for the treatment of chylothorax [19, 23,24,25,26]. The laparoscopic approach was not adopted in our patients because it prioritizes gentle manipulation of the gastric conduit. This approach may be adopted based on proficiency.
