What is the next step for a patient with a white material in the right chest drain after starting feeding via Nasogastric Tube (NGT) 24 hours post 3-stage esophagectomy?

Management of White Material in Chest Drain Post-Esophagectomy

CT thorax with oral contrast is the next step for a patient with white material in the right chest drain after starting NGT feeding post-esophagectomy. 1

Diagnostic Assessment

The white material in the chest drain 5 days after a 3-stage esophagectomy, which appeared after starting nasogastric tube feeding, strongly suggests an anastomotic leak with enteral feed entering the pleural space. This is a serious complication requiring immediate investigation and management.

Why CT with oral contrast is the correct choice:

• CT with oral contrast is the definitive test to identify and characterize an anastomotic leak
• It can visualize the exact location and extent of the leak
• It helps assess for other complications such as mediastinitis or abscess formation
• It provides crucial information for subsequent management decisions

Management Algorithm

1. Immediate investigation with CT thorax with oral contrast 1

   • Confirms presence and location of anastomotic leak
   • Assesses extent of contamination
   • Evaluates for associated complications

2. Subsequent management based on CT findings:

   • If contained leak: Consider conservative management with drainage
   • If non-contained leak: May require surgical intervention
   • If extensive contamination: May need more aggressive surgical approach

3. Nutritional management after diagnosis:

   • Discontinue NGT feeding immediately
   • Change to jejunal feeding (option C) or parenteral nutrition (option D) based on CT findings 1
   • For severe leaks, parenteral nutrition may be preferred until healing occurs

Why other options are less appropriate:

• MRI lymphangiogram (option B): Not the first-line investigation for suspected anastomotic leak; less sensitive than CT for this specific complication and would delay appropriate management

• Change to feeding via jejunal tube (option C): While this may ultimately be necessary, diagnosis must precede management changes; jejunal feeding would be appropriate after confirming a leak 1

• Change to parenteral nutrition (option D): Similar to option C, this may be required but only after confirming the diagnosis 1

• Change feed type to medium-chain triglyceride (option E): Changing formula composition will not address an anatomical defect like an anastomotic leak; diagnosis is required first

Important Considerations

• The timing (5 days post-op) is within the typical window for anastomotic leaks
• The appearance of white material coinciding with NGT feeding strongly suggests enteric content in the pleural space
• The substantial drain output (400mL/24h) indicates a significant issue requiring prompt attention

Pitfalls to Avoid

• Delaying diagnostic imaging while making nutritional changes can worsen outcomes
• Continuing enteral feeding through the current route could exacerbate contamination
• Failing to recognize an anastomotic leak can lead to sepsis, mediastinitis, and increased mortality

The World Journal of Emergency Surgery guidelines emphasize that prompt diagnosis and management of esophageal perforations are essential to reduce morbidity and mortality 1. CT with oral contrast remains the gold standard for diagnosing anastomotic leaks and should be performed without delay when this complication is suspected.