Outcome of a Step-Up Treatment Strategy for Chyle Leakage After Esophagectomy

Background: Thoracic chyle leakage is a major complication of esophagectomy. In this study our treatment strategy for chyle leakage was evaluated and its risk factors were identified. Methods: According to the Esophagectomy Complications Consensus Group recommendations, chyle leakage was classified as follows: I, enteric dietary modifications; II, total parenteral nutrition (TPN); and III, interventional or surgical therapy. It was graded as A, less than 1,000 mL per day; or B, more than 1,000 mL per day. In our protocol, chyle leakage less than 500 mL per day was treated with a low-fat diet; more than 1,000 mL per day, with TPN, and 500 to 1,000 mL per day, with a low-fat diet or TPN depending on whether the chyle leakage was increasing or decreasing at diagnosis and the clinical condition. Surgery was reserved for refractory leakages. Results: In total 371 patients were included. Chyle leakage incidence was 21%, consisting of 51% grade A and 49% grade B leakage. Chyle leakage severity was associated with length of stay (grade A, median 17 days versus B, 25 days; p = 0.006). Independent risk factors were a transthoracic approach (odds ratio 4.8, p = 0.002), neoadjuvant chemoradiotherapy (odds ratio 2.6, p = 0.002), and preoperative body mass index (exp(B) 0.92, p = 0.031). Treatment consisted of low-fat diet in 53%, TPN in 37%, and surgery in 10% of the patients. Low-fat diet and TPN successfully treated 87% of chyle leaks. Chyle leakages treated by TPN first were significantly more severe compared with those treated first by low-fat diet, and were significantly associated with electrolyte deficiencies, increased complication severity, and length of stay, but not with 90-day mortality. Conclusions: A step-up treatment strategy, starting with dietary modifications, solved nearly 90% of chyle leaks conservatively. A minority of chyle leaks required surgery.