Determining between chyle leak and anastomotic leak after esophageal reconstruction: The utility of methylene blue dye

Objectives/Hypothesis: Two common complications of esophagectomy and immediate reconstruction comprise thoracic duct injury leading to chyle leak and anastomotic leakage. These can delay optimized nutrition, speech, and swallowing rehabilitation, and thus are important to identify and treat accordingly. When either chyle leak or anastomotic leak are clinically suspected, differentiation between the two can be very difficult clinically. As both complications may result in an increase in drain output once oral intake has occurred, an effective, quick, and accurate tool is required to determine whether this increase in drain output is related to an anastomotic leak or with a increase activity in chyle production. Study Design: Retrospective descriptive study. Methods: Description of the use of oral methylene blue dye as a safe, simple, and quick clinical bedside test. Results: When ingested orally, an anastomotic leak will lead to blue dye staining the neck drain output immediately ( within seconds to minutes). A chyle leak may also result in blue staining of the drain output; however, this is not an immediate phenomenon, and rather, based on the bioavailability of methylene blue this would take a minimum of 1 hour, and more likely up to 4 hours, as the dye is absorbed into mesenteric lymphatics and travels via the thoracic duct. Conclusions: With no documented contraindications or side effects from its oral use ( in the absence of hypersensitivity reactions), methylene blue is an inexpensive and freely available test in the postoperative setting of esophageal reconstruction.