Selective En Masse Ligation of the Thoracic Duct to Prevent Chyle Leak After Esophagectomy Yidan Lin, MD, Zhihui Li, MD, Gang Li, MD, Xiaolong Zhang,

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Selective En Masse Ligation of the Thoracic Duct to Prevent Chyle Leak After Esophagectomy Yidan Lin, MD, Zhihui Li, MD, Gang Li, MD, Xiaolong Zhang, MD, Hanyu Deng, MD, Xiaoyan Yang, PhD, Lunxu Liu, MD The Annals of Thoracic Surgery Volume 103, Issue 6, Pages 1802-1807 (June 2017) DOI: 10.1016/j.athoracsur.2017.01.025 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Technique of the selective en masse ligation of the thoracic duct. (a) Because of preoperative olive oil intake, the intraoperative chyle leak can be easily identified as a milky white stream. (b) The pleura is incised and all the lymphofatty tissues between the azygous vein and aorta along the vertebral column are isolated and ligated with a heavy 0 silk suture. The en masse ligation in this patient included the azygous vein because there was significant adhesion. The en masse ligation is completed and the cessation of the chyle leaking proves that this ligation has been successful. (1 = chyle leak; 2 = lymphofatty tissues covering the thoracic duct; 3 = vertebral column; 4 = aorta; 5 = esophagus.) The Annals of Thoracic Surgery 2017 103, 1802-1807DOI: (10.1016/j.athoracsur.2017.01.025) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Preoperative olive oil intake facilitates visualization of the thoracic duct during the operation. Oral intake of 120 mL olive oil 4 to 12 hours before the operation can make the thoracic duct very well visualized at the level (a) above the innominate vein arch when applying a right thoracic approach or (b) at the level above the aortic arch when applying a left thoracic approach. (1 = thoracic duct; 2 = esophagus; 3 = aortic arch; 4 = left subclavian artery.) The Annals of Thoracic Surgery 2017 103, 1802-1807DOI: (10.1016/j.athoracsur.2017.01.025) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 An abnormal tributary (arrowhead) of the thoracic duct passes over the aorta (1) surface, and the milky chyle is leaking (arrow) from it after it was damaged during the operation. The Annals of Thoracic Surgery 2017 103, 1802-1807DOI: (10.1016/j.athoracsur.2017.01.025) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions