Post-Esophagectomy Chylothorax with Thoracic Duct Anomaly Successfully Treated with Lymphangiography: A Case Report.

Abstract

Introduction: Chylothorax following esophagectomy is a relatively rare but significant complication, with incidences ranging from 1.1% to 3.8%. It typically arises from damage to the thoracic duct or associated lymphatic vessels during extensive lymph node dissection and thoracic surgery. Initial management usually relies on conservative approaches such as dietary modifications, drainage, and pharmacotherapy. If these methods are ineffective, surgical intervention becomes necessary. However, standardized guidelines for the optimal management of thoracic duct injuries are as yet lacking, with decisions made on a case-by-case basis. We describe a case of chylothorax following esophagectomy where lymphangiography played a crucial role in guiding the surgical approach.

Case presentation: We report the clinical course of a 72-year-old male who developed chylothorax following esophagectomy for recurrent esophageal cancer. Despite initial conservative management, including octreotide and total parenteral nutrition, the patient's condition required further intervention. Lymphangiography performed on postoperative day (POD)14 revealed a rare anatomical variation of the thoracic duct, leading to successful surgical ligation through a right cervical approach. The patient's postoperative course was complicated by mediastinal fluid accumulation and resultant cardiac tamponade, necessitating emergency mediastinal drainage. Following the targeted surgical intervention, the drainage volume decreased, and the patient gradually resumed oral intake after swallowing function training. He was discharged on POD118.

Conclusions: Thoracic duct injury after esophagectomy is challenging, especially with anatomical variations. Lymphangiography enables precise localization, guides surgery, and improves outcomes in chylothorax patients. The literature confirms that its early use reduces hospital stays and complications. Tumor invasion or inflammation at or beyond T3 may increase surgical complexity and injury risk. Given its diagnostic and therapeutic benefits, lymphangiography should be integrated into the standard protocols for chylothorax, especially in cases in where conservative treatment fails or anatomical variations are suspected.