Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers
Authors: Kamarajah Sivesh K. , Siddaiah-Subramanya Manjunath , Parente Alessandro , Evans Richard P. T. , Adeyeye Ademola , Ainsworth Alan , Takahashi Alberto M. L. , Charalabopoulos Alex , Chang Andrew , Eroglue Atila , Wijnhoven Bas , Donohoe Claire , Molena Daniela , Talavera-Urquijo Eider , Takeda Flavio Roberto , Darling Gail , Rosero German , Piessen Guillaume , Mahendran Hans , Kuei Hsu Po , Gockel Ines , Negoi Ionut , Weindelmayer Jacopo , Rasanen Jari , Bekele Kebebe , Kim Guowei , Depypere Lieven , Ferri Lorenzo , Nilsson Magnus , Klevebro Frederik , Smithers B. Mark , van Berge Henegouwen Mark I. , Grimminger Peter , Schneider Paul M. , Pramesh C. S. , Sayyed Raza , Babor Richard , Mine Shinji , Law Simon , Gisbertz Suzanne , Bright Tim , Benoit D’Journo Xavier , Low Donald , Singh Pritam , Griffiths Ewen A ,   on behalf of the Oesophagogastric Anastomosis Audit collaborative
Published: August 2022

Objective:
This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice.

Background:
Chyle leaks following esophagectomy for malignancy are uncommon. Although they are associated with increased morbidity and mortality, diagnosis and management of these patients remain controversial and a challenge globally.

Methods:
This was a modified Delphi exercise was delivered to clinicians across the oesophagogastric anastomosis collaborative. A 5-staged iterative process was used to gather consensus on clinical practice, including a scoping systematic review (stage 1), 2 rounds of anonymous electronic voting (stages 2 and 3), data-based analysis (stage 4), and guideline and consensus development (stage 5). Stratified analyses were performed by surgeon specialty and surgeon volume.

Results:
In stage 1, the steering committee proposed areas of uncertainty across 5 domains: risk factors, intraoperative techniques, and postoperative management (ie, diagnosis, severity, and treatment). In stages 2 and 3, 275 and 250 respondents respectively participated in online voting. Consensus was achieved on intraoperative thoracic duct ligation, postoperative diagnosis by milky chest drain output and biochemical testing with triglycerides and chylomicrons, assessing severity with volume of chest drain over 24 hours and a step-up approach in the management of chyle leaks. Stratified analyses demonstrated consistent results. In stage 4, data from the Oesophagogastric Anastomosis Audit demonstrated that chyle leaks occurred in 5.4% (122/2247). Increasing chyle leak grades were associated with higher rates of pulmonary complications, return to theater, prolonged length of stay, and 90-day mortality. In stage 5, 41 surgeons developed a set of recommendations in the intraoperative techniques, diagnosis, and management of chyle leaks.

Conclusions:
Several areas of consensus were reached surrounding diagnosis and management of chyle leaks following esophagectomy for malignancy. Guidance in clinical practice through adaptation of recommendations from this consensus may help in the prevention of, timely diagnosis, and management of chyle leaks.