P1.146. Escaping the Operating Room: Minimally Invasive Lymphatic Embolization for High-Output Post-Esophagectomy Chyle Leaks

Abstract

Esophageal Cancer: Other Chyle leak following esophagectomy is a rare but life-threatening complication associated with significant morbidity, prolonged hospitalization, and mortality. While conventional management relies heavily on prolonged conservative measures or morbid surgical ligation, minimally invasive lymphangiographic embolization has recently emerged as a highly promising treatment alternative for these critically ill patients. This prospective cohort study evaluated five consecutive patients who developed refractory chyle leaks following esophagectomy for esophageal carcinoma at a high-volume tertiary cancer centre between January 2023 and December 2024. Patients were included if they demonstrated high-output chyle leaks exceeding 500 ml per day that remained unresponsive to a strict trial of conservative management, including total parenteral nutrition, medium-chain triglyceride dietary modifications and intravenous octreotide medical therapy for at least forty-eight hours. Upon failure of conservative measures, all patients underwent targeted percutaneous or transvenous lymphangiography followed by embolization. We systematically collected and analysed clinical demographics, surgical details, precise lymphangiographic anatomical findings, catheterization techniques, specific embolic agents utilized, and overall clinical outcomes (Table 1). The primary study endpoint was defined as complete clinical resolution of the chyle leak. Secondary endpoints evaluated procedural technical success, procedure-related adverse events, hospital length of stay and long-term recurrence rates during the comprehensive postoperative follow-up period. All five patients initially presented with high-output chyle leaks exceeding 500 ml daily. Diagnostic lymphangiography successfully visualized and anatomically localized the exact site of the leak in all cases: the proximal thoracic duct in the chest (n=3), the distal thoracic duct in the neck (n=1), and the right lymphatic tributary duct (n=1). Catheterization was successfully achieved utilizing diverse approaches tailored to patient anatomy: percutaneous puncture of the cisterna chyli (n=2), direct percutaneous access of the proximal thoracic duct (n=2), and retrograde transvenous cannulation via the basilic vein (Image 1) for the distal thoracic duct (n=1). Embolization utilizing a precisely concentrated N-butyl cyanoacrylate (NBCA) glue mixture was technically successful in all patients. Complete clinical leak resolution and subsequent thoracic drain removal occurred at a median of three days (range 2 - 5). No severe procedure-related adverse events, embolic complications, or leak recurrences were noted over a median follow-up period of twelve months. Lymphangiographic embolization utilizing strictly cyanoacrylate glue without coiling represents a highly safe, effective, and minimally invasive therapeutic treatment for refractory post esophagectomy chyle leaks. By completely avoiding the substantial morbidity of surgical reintervention, this novel strategy offers an immensely valuable management option. Although this prospective cohort provides robust evidence of excellent outcomes and durability over a one year follow up, larger multi-centre studies are still definitively warranted to comprehensively validate these crucial clinical interventional findings.