Transhiatal Chest Drainage in Transmediastinal Esophagectomy for Esophageal Cancer: A Retrospective Study

doi:10.21203/rs.3.rs-1302099/v1

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Transhiatal Chest Drainage in Transmediastinal Esophagectomy for Esophageal Cancer: A Retrospective Study

https://doi.org/10.21203/rs.3.rs-1302099/v1

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Background: Transmediastinal esophagectomy for esophageal cancer occasionally causes postoperative accumulation of pleural effusion despite the preservation of the mediastinal pleura. Transhiatal chest drainage has been reported to be useful for thoracic esophagectomy; however, its use in transmediastinal esophagectomy remains unelucidated. This study aimed to evaluate the effectiveness and safety of transhiatal chest drainage in transmediastinal esophagectomy.

Methods: This retrospective study included patients who underwent transmediastinal esophagectomy for esophageal cancer from 2018 to 2021. Transhiatal chest drainage involved the insertion of a 19-Fr Blake® drain from the abdomen to the left thoracic cavity through the hiatus. We assessed its effectiveness and safety by the daily drainage output, accumulation of postoperative pleural effusion, frequency of postoperative thoracentesis, and other complications. The drainage group comprising 24 patients was compared with the non-drainage group comprising 13 patients in whom a transhiatal chest drainage tube was not placed during transmediastinal esophagectomy.

Results: The median daily output of the transhiatal chest drainage was 230 mL on day 1, 385 mL on day 2, and 313 mL on day 3. The number of patients with postoperative pleural effusion was significantly reduced from 10/13 (76.9%) in the non-drainage group to 4/24 (16.7%) in the drainage group (p=0.001). The frequency of thoracentesis in the drainage group was significantly lower than that in the non-drainage group (p=0.002). There were no significant differences in the occurrence of other postoperative complications.

Conclusions: Transhiatal chest drainage could evacuate pleural effusion effectively and safely after transmediastinal esophagectomy.

esophageal cancer

pleural effusion

Transhiatal chest drainage

transmediastinal esophagectomy

Chest drainage is essential for full lung expansion in the postoperative management of esophagectomy due to the clinical consequences of pleural effusion [1]. Transmediastinal radical esophagectomy for esophageal cancer is not performed through the thoracic approach [2, 3]. Theoretically, this surgical procedure limits and prevents the exposure of the pleural cavity. However, transmediastinal esophagectomy also causes the accumulation of pleural effusion despite the preservation of the mediastinal pleura, especially in the left thoracic cavity [4]. Therefore, the placement of an effective chest drainage tube is essential for esophagectomy, even when a transmediastinal approach is used.

Although the placement of an intercostal chest drainage tube is a standard practice in transthoracic esophagectomy, the intercostal drainage is inappropriate for the transmediastinal approach, where the surgical field is far from the thoracic wall. Transhiatal chest drainage, which was reportedly used for transthoracic esophagectomy, can be inserted into the thoracic cavity via laparoscopy without manipulating the thoracic wall [5, 6]. However, we have found no studies assessing its use in transmediastinal esophagectomy.

Thus, this study evaluated the effectiveness and safety of transhiatal chest drainage in transmediastinal esophagectomy by the drainage output of the drain, by the accumulation of postoperative pleural effusion, and by comparing the incidence of thoracentesis and other complications with or without a transhiatal chest drainage tube.

Patient characteristics

This retrospective study included all patients who underwent transmediastinal esophagectomy for esophageal cancer at the Tsukuba University Hospital from 2018 to 2021. We excluded patients who had a history of lung surgery, converted to thoracotomy, developed pneumothorax, and required tube drainage at the time of wound closure, underwent simultaneous surgery for a second cancer, or whose gastric conduit could not be used.

Procedure

All patients underwent transcervical, transmediastinal esophagectomy with radical lymph node dissection, followed by the laparoscopic transhiatal approach, as described previously [2, 3]. In almost all patients, abdominal and transhiatal procedures were performed laparoscopically; in seven patients, the procedures were hand-assisted. In this study, patients were divided into two groups, namely the with or without transhiatal chest drainage groups. In the drainage group, the transhiatal left chest drainage tube was placed after esophagectomy and lymph node dissection; the drainage tube was inserted from the inferior hepatic space to the left thoracic cavity blindly through the hiatus by intentional left pleural incision before hiatal closure (Figs. 1 and 2). In the non-drainage group, the pleura was preserved, and the hiatus was closed directly. We used a 19-Fr Blake® (Ethicon, Inc., Somerville, NJ, USA) drain connected to a portable vacuum system (J-Vac®; Ethicon). Reconstruction was performed using a gastric conduit via the retrosternal route with cervical anastomosis. Transhiatal chest drainage, introduced in February 2020, has been used in all patients since. Using the immediate postoperative radiograph (Fig. 3), patients were assigned to the drainage and non-drainage groups.

To assess the effectiveness and safety of transhiatal chest drainage, the primary outcome measure was daily drainage output and the accumulation of postoperative pleural effusion. The secondary outcome was the frequency of postoperative thoracentesis and other complications. Chest radiography was performed everyday until postoperative day 5 to evaluate the accumulation of pleural effusion. The indication for postoperative thoracentesis was the accumulation of pleural effusion, which was diagnosed by radiography and required oxygen administration. Thoracentesis was avoided for patients who could not be punctured safely on ultrasonography. The other following data were collected from the clinical database: age, sex, body mass index (BMI), tumor location, and T stage based on the 7th edition of the AJCC/UICC TNM classification system [7], lymph node metastasis status, histological type, neoadjuvant chemotherapy, operation time, blood loss volume, number of dissected lymph node, frequency of postoperative thoracentesis and its complications, drained volume of pleural effusion, occurrence of postoperative complications (grade 3 or more) based on the Clavien–Dindo classification [8], duration of oxygen administration, percentage of body weight loss on postoperative day (POD) 14, and duration of postoperative hospital stay. In the drainage group, the procedure time to insert the transhiatal drainage tube was measured. The study’s retrospective protocol was approved by our institutional review board (No. R1-017), and written informed consent for publication was obtained from the patients.

Statistical analysis

Comparisons between the drainage and non-drainage groups were performed using the chi-square test for categorical variables (sex, tumor location, T stage, lymph node metastasis, histological type, and occurrence of postoperative complications) and the Mann–Whitney U test for continuous variables (age, BMI, operation duration, blood loss volume, number of dissected lymph nodes, duration of oxygen administration, and postoperative hospital stay). All analyses were performed using IBM SPSS Statistics for Windows version 25.0 (IBM Corp., Armonk, NY, USA). P-values <0.05 were considered statistically significant.

Patient demographics

During the study period, 44 patients underwent transmediastinal esophagectomy. We excluded 7 patients owing to their history of lung surgery (n=1), conversion to thoracotomy (n=2), pneumothorax at wound closure (n=2), simultaneous surgery for hypopharyngeal cancer (n=1), and an unusable gastric conduit (n=1). A total of 37 patients were enrolled; in 24 patients, a transhiatal drainage tube was placed intraoperatively (drainage group), and in the other 13 patients, a drainage tube was not placed (non-drainage group). The clinical characteristics of the patients are shown in Table 1. There were no significant differences in clinical parameters between the groups.

Table 1

Clinical data of the drainage and non-drainage groups
	Drainage n=24	Non-drainage n=13	p-value
Age, years (IQR)^a	70 (69–74)	71 (67–75)	0.96
Male/female	20/4	8/5	0.14
BMI^b (IQR)	23.0 (20.0–25.1)	22.0 (18.9–23.4)	0.26
Thoracic esophagus /esophagogastric junction	14/10	9/4	0.51
cT 1/2/3/4	6/7/9/2	2/5/6/0	0.20
cN (+)/(−)	16/8	9/4	0.97
Squamous cell carcinoma /adenocarcinoma	12/12	9/4	0.26
Neoadjuvant chemotherapy	18 (75.0%)	11 (84.6%)	0.50
^aInterquartile range; ^bBody mass index

Intraoperative outcomes

Table 2 shows intraoperative outcomes. The median and interquartile range (IQR) time to insert the transhiatal drainage tube was 4 (3–5) min in the drainage group. All 24 patients enrolled in the drainage group were able to undergo transhiatal chest drainage tube insertion as confirmed by postoperative radiography. There were no significant differences in operative time, blood loss, and the number of resected lymph nodes between the groups. All patients underwent R0 resection.

Table 2

Operative data of the drainage and non-drainage groups
	Drainage n=24	Non-drainage n=13	p-value
Drain insertion time (IQR) ^a	4 (3–5)	–	–
Operation time, min (IQR)	425 (348–480)	415 (390–459)	0.97
Blood loss volume, mL (IQR)	110 (52–191)	124 (79–158)	0.83
Dissected nodes (IQR)	39 (33–54)	38 (28–47)	0.63
^aInterquartile range

Postoperative outcomes

The daily drainage output is shown in Figure 4. The median volume in the drainage group was 230 mL on day 1, 385 mL on day 2, and 313 mL on day 3. The number of patients drained over 350 mL/day was 19/24 (79.2%). The median volume of drainage output decreased by to 200 mL after POD 5. The transhiatal drainage tube was removed after a median time of POD 6. The postoperative data are shown in Table 3. In the non-drainage group, the accumulation of pleural effusion was observed on chest radiography in 10/13 (76.9%). In contrast, the number of patients significantly decreased to only 4/24 (16.7%) in the drainage group. Thoracentesis was required 7 times for 6 patients in the non-drainage group until POD 2. The median (IQR) volume evacuated by one thoracentesis was 450 (375-600) mL in the non-drainage group. One patient in the non-drainage group developed pneumothorax after thoracentesis. All 6 patients required left-side thoracentesis. In contrast, one patient in the drainage group, who also had anastomotic leakage, required right thoracentesis; this number was significantly less than that in the non-drainage group (p=0.002). Further, the patient in the drainage group did not require left thoracentesis, which also varied from the findings in the non-drainage group (p=0.001). There were no significant differences between both groups in the occurrence of postoperative complications, duration of oxygen administration, and length of postoperative hospital stay.

Table 3

Postoperative data of the drainage and non-drainage groups
	Drainage n=24	Non-drainage n=13	p-value
Accumulation of pleural effusion	4 (16.7%)	10 (76.9%)	0.001
Thoracentesis	1 (4.2%)	6 (46.2%)	0.002
Left	0	6	0.001
Right	1	0	0.47
Pneumothorax caused by thoracentesis	0 (0%)	1 (7.7%)	0.17
Other complications	8 (33.3%)	4 (30.8%)	0.87
Respiratory	3 (12.5%)	1 (7.7%)	0.65
Anastomotic leakage	3 (12.5%)	1 (7.7%)	0.65
SSI^a	3 (12.5%)	1 (7.7%)	0.65
Chylothorax	0 (0%)	1 (7.7%)	0.17
Duration of oxygen administration, days (IQR)^b	3 (1–4)	4 (2–6)	0.40
Postoperative hospital stay, days (IQR)	18 (13–21)	14 (12–18)	0.30
^aSurgical site infection; ^bInterquartile range

Transhiatal chest drainage in transmediastinal esophagectomy could be performed in a short time intraoperatively to evacuate postoperative pleural effusion effectively and reduce the frequency of atelectasis requiring postoperative thoracentesis, which carries the risk of iatrogenic pneumothorax. Furthermore, the transhiatal chest drainage system did not employ an underwater seal but a portable vacuum system, which was reportedly easy to insert and safe in terms of other complications. Despite not being able to control the drain tip position from the transabdominal view, pleural effusion was evacuated effectively. Currently, no study has discussed the suitability of an indwelling transhiatal chest drainage tube in transmediastinal esophagectomy. To the best of our knowledge, this study is the first to assess the effective and safe evacuation of pleural effusion via intraoperative placement of a chest drainage tube in transmediastinal esophagectomy.

A single Blake drain inserted through the abdominal wall effectively evacuated pleural effusion in this study. Moreover, the placement of the transhiatal chest drainage tube was a simple procedure, which was completed in <6 min. The utility of a mediastinal drainage tube from the abdominal wall through the hiatus after thoracic esophagectomy has been reported [9]. Transhiatal chest drainage using a Blake drain has also been reported to be effective and safe in Ivor Lewis esophagectomy [6]. The insertion of a chest drainage tube intraoperatively via the intercostal space is obviously difficult in transmediastinal esophagectomy, and in such cases, transhiatal chest drainage is appropriate.

The median volume of drainage output by transhiatal chest drainage was approximately 300 mL for 3 days postoperatively. Daily physiological pleural fluid filtration is estimated to be 350 mL/day [10, 11]. The number of patients drainaged over 350 mL/day was 19 (79.2%), thus, transhiatal chest drainage would have been effective for these patients. Furthermore, approximately the same amount of pleural effusion was drained by thoracentesis in more than half of the patients in the non-drainage group. Therefore, in these patients, transhiatal chest drainage may have been effective. In contrast, the adequate duration of drainage postoperatively was unclear in this study. In the non-drainage group, thoracentesis was required until POD 2. In the drainage group, the median volume of drainage output decreased to <200 mL after POD 5. The indwelling period for the drainage tube could be potentially shortened.

In this study, we used a 19-Fr Blake drain connected to a portable vacuum system. The use of a portable vacuum system connected to the Blake drain is a viable alternative to an underwater seal [6, 12, 13]. A single Blake drain inserted from the right intercostal space into the left thoracic cavity across the mediastinum is useful for the drainage of the left pleural effusion after thoracic esophagectomy [14]. Transhiatal chest drainage in transmediastinal esophagectomy had similar effects to these drainage systems. Despite other studies describing the use of a 15-Fr drain [6, 14], we used a 19-Fr drain. The 15-Fr drain is more beneficial than the 19-Fr one in terms of preventing dislocation, excessive drainage, and pain caused to patients [14]. Further clinical experiences are needed to clarify the appropriate drain size.

This study had some limitations. First, this study was retrospective with a small sample size; thus, patient characteristics, including sex, histological types, and progression, were not homogenous. Second, this study did not compare transhiatal chest drainage with conventional thoracic drainage. However, the inferiority of thoracic drainage might be definitive owing to the difficulty of the thoracic approach in transmediastinal esophagectomy. Third, transhiatal chest drainage could not improve the clinical outcomes associated with oxygenation, including the duration of oxygen administration, respiratory complications, and postoperative hospital stay, although the patients were spared from thoracentesis. Further studies are required to validate these findings.

We demonstrated that transhiatal chest drainage was an effective, safe, and simple procedure to evacuate pleural effusion after transmediastinal esophagectomy. Moreover, this procedure may reduce the frequency of postoperative thoracentesis. A large, prospective randomized controlled trial is required to completely assess the benefits and limitations of transhiatal chest drainage.

BMI: Body mass index; POD: Postoperative day; IQR: Interquartile range; SSI: Surgical site infection

Ethics approval and consent to participate

This study was performed in accordance with the principles of the Declaration of Helsinki and its later amendments, and was approved by the Ethics Committee of Tsukuba University Hospital (No. R1-017).

Consent for publication

Written informed consent for publication of this case report was obtained from the patients.

Availability of data and materials

Not applicable.

Competing interests

The authors declare that they have no competing interest.

Funding

The funder “Hitachi Ltd” provided support in the form of salaries for author KH, but it did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ contributions

KH, KO, and YA performed the surgery. KH acquired the data and drafted the manuscript. KH, KO, YA, SM, YO, YO, SH, TE, and TA revised the article. JK drew the diagrams for the figures. All authors have read and approved the final manuscript.

Acknowledgments

We would like to thank Dr. Fujiwara (Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine) for his help in the transmediastinal esophagectomy procedures.

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Editorial decision: Major revision
08 Jul, 2022
Reviewers agreed at journal
12 Jun, 2022
Reviewers invited by journal
12 Jun, 2022
Editor assigned by journal
28 Jan, 2022
First submitted to journal
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Transhiatal Chest Drainage in Transmediastinal Esophagectomy for Esophageal Cancer: A Retrospective Study

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Abstract

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Background

Materials And Methods

Statistical analysis

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Discussion

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