Traitement du chylothorax

Anatomical study of the thoracic duct and its clinical implications in thoracic and pediatric surgery, a 70 cases cadaveric study

INTRODUCTION

Given the high variability and fragility of the thoracic duct, good knowledge of its anatomy is essential for its repair or to prevent iatrogenic postoperative chylothorax. The objective of this study was to define a site where the thoracic duct is consistently found for its ligation. The second objective was to define an anatomically safe surgical pathway to prevent iatrogenic chylothorax in surgery for aortic arch anomalies with vascular ring, through better knowledge of the anatomical relationships of the thoracic duct.

METHODS

Seventy adult formalin-fixed cadavers were dissected. The anatomical relationships of the thoracic duct were reported at the postero-inferior mediastinum, at levels T3 and T4.

RESULTS

The thoracic duct was consistently situated between the left anterolateral border of the azygos vein and the right border of the aorta between levels T9 and T10, whether it was simple, double, or plexiform. It was located medially, anteromedially, or posteriorly to the left subclavian artery in 51%, 21%, and 28% of the cases, respectively, at the level of T3. At T4, it was posteromedial in 27% of the cases or had no direct relationship with the aortic arch.

CONCLUSION

These results favor mass ligation of the thoracic duct at levels T9-T10 between the right border of the aorta and the azygos vein, eventually including the latter. To prevent iatrogenic postoperative chylothorax in aortic arch anomalies with vascular ring surgery, we recommend remaining strictly lateral to the left subclavian artery at the level of T3 to reach the aortic arch anomalies with vascular ring at T4.