Anatomic and pathologic studies of the thoracic duct

Inguinal intranodal lymphangiography reveals a high incidence of suprainguinal lymphatic disease in patients with leg edema undergoing stenting for symptomatic chronic iliofemoral venous obstruction

OBJECTIVE

Recent studies have emphasized the important role lymphatics play in the drainage of interstitial fluid and edema prevention. Although the infrainguinal lymphatics have been studied in some depth, with patterns of pathology identified, such data above the groin are sparse, especially for patients with phlebolymphedema. The present study attempts to evaluate the status of lymphatic flow above the inguinal ligament in patients presenting with edema and undergoing stenting for symptomatic chronic iliofemoral venous obstruction (CIVO).

METHODS

A total of 31 lower limbs that underwent pedal lymphoscintigraphy for leg edema and subsequent stenting for symptomatic CIVO formed the study cohort. Each limb underwent intranodal lymphangiography of an ipsilateral inferior inguinal lymph node (10 mL of lipiodol) at the time of stenting. Fluoroscopic visualization of lipiodol transit was performed at 20, 40, and 60 minutes and 3 hours after injection. Enumeration of the lymph nodes and lymphatic collector vessels from above the inguinal ligament to L1, visualization of the thoracic duct, the time delay to visualization of the thoracic duct, and pathologic changes to the thoracic duct when present were all evaluated. These anomalies were independently scored, with the scores combined to generate a total suprainguinal score (range, 0-3). This score was then compared to the limb's lymphoscintigraphically derived infrainguinal score (total infrainguinal score range, 0-3) using the t test and Spearman correlation. The clinical outcomes (grade of swelling, venous clinical severity score) after stenting were appraised.

RESULTS

Of the 30 patients (31 limbs), 18 were women, with left laterality noted in 23 limbs. A nonthrombotic iliac vein lesion occurred in 9 limbs and post-thrombotic syndrome in 22 limbs. Of the 31 limbs, 24 (77%) had suprainguinal lymphatic disease (SLD), with 22 of the 24 limbs having severe SLD and 2, mild SLD. When SLD was compared with infrainguinal lymphatic disease, 6 limbs (19%) had the same degree of involvement above and below the groin (1 with normal and 5 with severe disease), 17 limbs (55%) had more severe SLD, and 8 limbs (26%) had more severe infrainguinal lymphatic disease. Three limbs with normal pedal lymphoscintigraphic findings had severe SLD. The Spearman correlation coefficient for the comparison of SLD and infrainguinal disease in the same limb was 0.1 (P = .69). At baseline, the limbs with severe SLD had the same degree of leg swelling and venous clinical severity score as the limbs with absent to mild SLD (P > .1) with similar improvements after stenting (P > .4). Seven limbs underwent complex decongestive therapy (all with severe SLD and concomitant severe infrainguinal disease in one) to treat significant residual leg edema, with improvement.

CONCLUSIONS

SLD appears to be common in patients with leg edema undergoing stenting for symptomatic CIVO. Such disease appears to affect the thoracic duct more commonly. Although patients with persistent or residual leg edema after stenting can benefit from complex decongestive therapy, further workup in the form of inguinal intranodal lymphangiography and targeted intervention might need to be considered for those who do not benefit from such therapy. Further study is warranted.

The cisterna chyli: a systematic review of definition, prevalence, and anatomy

The cisterna chyli is a lymphatic structure found at the caudal end of the thoracic duct that receives lymph draining from the abdominal and pelvic viscera and lower limbs. In addition to being an important landmark in retroperitoneal surgery, it is the key gateway for interventional radiology procedures targeting the thoracic duct. A detailed understanding of its anatomy is required to facilitate more accurate intervention, but an exhaustive summary is lacking. A systematic review was conducted, and 49 published human studies met the inclusion criteria. Studies included both healthy volunteers and patients and were not restricted by language or date. The detectability of the cisterna chyli is highly variable, ranging from 1.7 to 98%, depending on the study method and criteria used. Its anatomy is variable in terms of location (vertebral level of T10 to L3), size (ranging 2-32 mm in maximum diameter and 13-80 mm in maximum length), morphology, and tributaries. The size of the cisterna chyli increases in some disease states, though its utility as a marker of disease is uncertain. The anatomy of the cisterna chyli is highly variable, and it appears to increase in size in some disease states. The lack of well-defined criteria for the structure and the wide variation in reported detection rates prevent accurate estimation of its natural prevalence in humans.

Lymphangiography and Lymphatic Interventions

Compared with the traditional pedal lymphangiography, intranodal lymphangiography and MR lymphangiography have made imaging of the lymphatic system less challenging. Improvements in imaging and availability of newer catheters have allowed embolization of lymphatic system much more feasible that previously envisioned. In this article, we briefly review the anatomy, imaging, and current and future of lymphatic interventions.

Management of High-Output Chyle Leak after Harvesting of Vascularized Supraclavicular Lymph Nodes

Vascularized lymph node transfer is a physiologic microsurgical technique used for the treatment of lymphedema. As vascularized lymph node transfer is becoming more common, it is essential that one is aware of all potential complications associated with vascularized lymph node transfer and know how to avoid and manage them when they do occur. The authors recently encountered a complication after supraclavicular vascularized lymph node transfer that has not been previously reported. A patient developed a recalcitrant high-output (>500 ml/day) chyle leak in the neck donor site after supraclavicular vascularized lymph node transfer harvest. In this article, the authors share their experience with massive chyle leak and review the management strategies of how to effectively avoid and treat this potentially dangerous complication. This review of a previously unreported complication of supraclavicular vascularized lymph node transfer is timely and important, as this procedure is increasingly being offered to patients, and surgeons performing these procedures should be familiar with effectively managing this potentially dangerous complication. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes

OBJECTIVE

To summarize the imaging findings and outcomes of thoracic duct (TD) embolization (TDE) performed in patients with chylous leaks persisting after TD ligation (TDL).

MATERIALS AND METHODS

In this review of 50 patients (30 males and 20 females; median age, 54 years) referred for TDE following unsuccessful surgical TDL, records were reviewed for lymphangiographic findings, technical success of TDE, and outcome of TDE. Comparisons between groups were performed using the Fisher exact test.

RESULTS

The causes of chylothorax were traumatic in 39 patients (78%) and nontraumatic in 11 (22%). Lymphangiography identified missed TDL in 30 patients (60%) and complete TDL in 15 patients (30%); however, in 12 of these 15 patients, collaterals around the ligation site supplying the leak could be identified. Incomplete ligation was observed in 4 patients (8%). In 1 patient (2%), a second TD was identified circumventing a complete ligation of the main TD. TDE was performed in 49 patients, and TD disruption was performed in 1 patient. Resolution of the chylous leak occurred in 45 patients (90%). There were 3 minor complications that resulted in no clinical sequela.

CONCLUSIONS

TDE produced cessation of chylous leak in the majority of the patients with persistent chylothorax after surgical TDL. Missed ligation is the most common finding on lymphangiography in patients with failed TDL. These findings support the use of image-guided closure of TD leaks.

Modern Techniques of Lymphangiography and Interventions: Current Status and Future Development

One of the crucial functions of the lymphatic system is maintenance of fluid balance. Nonetheless, due to lack of clinical imaging and interventional techniques, the lymphatic system has been under the radar of the medical community. The recently developed intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography provide new insight into lymphatic pathology. Thoracic duct embolization has become the method of choice for the treatment of patients with chylous leaks. Interstitial lymphatic embolization further expanded the lymphatic embolization approaches. Liver lymphatic lymphangiography and embolization allow treatment of postsurgical liver lymphorrhea and protein-losing enteropathy. The potential for further growth of lymphatic interventions is vast and includes liver lymphatic procedures and advanced thoracic duct interventions, such as thoracic duct externalization and stenting. These current and future advances will open up a realm of new treatments and diagnostic opportunities.

Abnormalities Associated with Aberrant Right Subclavian Arteries

An aberrant right subclavian artery (ARSA) is an anomaly with a reported incidence of 0.5% to 2%. Usually the aberrant artery follows a retroesophageal course; rarely it takes a course anterior to the esophagus or the trachea. Most patients with an ARSA remain asymptomatic; however, progressive dysphagia develops occasionally. The choice of approach depends on the presence or absence of aneurysmal disease, the urgency of the operation, and the surgeon's experience. A case is reported of a 33-year-old white male patient who had a 3-year history of progressive dysphagia to the point that he was only able to swallow liquids. A barium swallow demonstrated a posterior extrinsic compression of the esophagus. Angiography was performed, which demonstrated an ARSA with a common origin of the right and left common carotid arteries. Surgical correction was performed via a right supraclavicular neck incision. The proximal aberrant artery was mobilized behind the esophagus. The distal, right subclavian artery was exposed, transected, and transposed with reimplantation into the right common carotid artery. An aberrant right thoracic duct was encountered and ligated. The English language literature from 1960 to present was reviewed via a Medline search. Reported anomalies associated with ARSAs include a nonrecurrent right inferior laryngeal nerve, a common origin of the common carotid arteries, a replaced right or left vertebral artery, coarctation of the aorta, a right-sided thoracic duct, and a right-sided aortic arch. It is important to be aware of these associated anomalies and how they impact the operative approach involved in the correction of dysphagia lusoria.

The thoracic duct: clinical importance, anatomic variation, imaging, and embolization

The thoracic duct is the body's largest lymphatic conduit, draining upwards of 75 % of lymphatic fluid and extending from the cisterna chyli to the left jugulovenous angle. While a typical course has been described, it is estimated that it is present in only 40-60% of patients, often complicating already challenging interventional procedures. The lengthy course predisposes the thoracic duct to injury from a variety of iatrogenic disruptions, as well as spontaneous benign and malignant lymphatic obstructions and idiopathic causes. Disruption of the thoracic duct frequently results in chylothoraces, which subsequently cause an immunocompromised state, contribute to nutritional depletion, and impair respiratory function. Although conservative dietary treatments exist, the majority of thoracic duct disruptions require embolization in the interventional suite. This article provides a comprehensive review of the clinical importance of the thoracic duct, relevant anatomic variants, imaging, and embolization techniques for both diagnostic and interventional radiologists as well as for the general medical practitioner.

KEY POINTS

• Describe clinical importance, embryologic origin, and typical course of the thoracic duct. • Depict common/lesser-known thoracic duct anatomic variants and discuss their clinical significance. • Outline the common causes of thoracic duct injury and indications for embolization. • Review the thoracic duct embolization procedure including both pedal and intranodal approaches. • Present and illustrate the success rates and complications associated with the procedure.

The surgical anatomy and clinical relevance of the neglected right lymphatic duct: review

BACKGROUND

The major lymphatic vessels may be damaged during neck dissection or other cervical surgery, resulting in chyloma or chyle fistula. While commonly considered to be predominantly a complication of left-sided surgery, the thoracic duct may be damaged on either side of the neck due to the extreme variability in the anatomy of the central lymphatic system.

METHOD AND RESULTS

This paper reviews the variable anatomy and embryology of the thoracic and right lymphatic ducts, particularly aspects relevant to head and neck surgery.

Massive Chylorrhea following Total Thyroidectomy and Neck Dissection

Chylorrhea, following thyroid surgery, is a known complication mentioned in the literature, but massive chylorrhea is uncommonly encountered. Here, we report two such cases of thyroid malignancy (papillary carcinoma) where the patient developed massive chylorrhea following total thyroidectomy and neck dissection, one of whom underwent tracheal resection and anastomosis in addition. The patient, in whom only total thyroidectomy and neck dissection was done, developed encysted chyloma postoperatively which was managed surgically. The other patient who underwent neck exploration twice for his chylorrhea but later developed septicemia and succumbed to it. Development of chyloma following neck surgery is not a common entity, very few cases have been reported.

How to cite this article

Thiagarajan S, Shenoy AM, Veerabadriah P, Chavan P, Halkud R. Massive Chylorrhea following Total Thyroidectomy and Neck Dissection. Int J Head and Neck Surg 2012;3(1):45-48.

Traumatic chyle leak: a rare complication of left internal jugular venous cannulation

A traditional method for internal jugular vein catheterization has been through the transjugular approach. These days, ultrasound-guided cannulation is the preferred mode because of the higher success and lower complication rates. Complications associated with the transjugular approach include neck hematoma caused by carotid artery puncture, pleural puncture leading to pneumothorax and air embolism. Thoracic duct injury is a rare complication of left internal jugular vein catheterization. This complication occurred in one of the patients in whom ultrasound-guided left internal jugular vein catheterization was used. The anatomical basis of this injury is discussed here.

Reconstruction of occluded thoracic duct for treatment of chylopericardium: a novel surgical therapy

Chylopericardium is an uncommon disease predominantly caused by trauma. Prolonged chyle depletion may result in nutritional, metabolic, and immunologic deficiencies due to loss of essential proteins, immunoglobulins, fat, vitamins, electrolytes, and water. Medical treatment includes a low-fat diet with medium-chain triglyceride restriction, cardiac support, diuretic medications, and drainage of the pericardial effusion. Conventional surgical therapy consists of pericardial fenestration and thoracic duct ligation. We report a case of massive secondary chylous pericardial effusion successfully treated with microsurgical lymphovenous anastomosis, reconnecting the occluded thoracic duct to the internal jugular vein. This case highlights features and management strategies of this perplexing clinical condition.

Treatment of chylothorax by robotic thoracic duct ligation

This is the first report describing the use of robotic technology for the treatment of chylothorax. We present a 22-year-old with mixed embryonal cell and seminoma germ cell cancer refractory to medical and surgical treatment. The patient had rising markers and a growing left lower lung lobe metastasis. After left lower lobectomy, left-sided chylothorax developed. Conservative management failed, and a robotic right-sided thoracic duct ligation was performed. Other treatment options are reviewed.

Cisterna chyli: A detailed anatomic investigation

With recent laparoscopic advancements in retroperitoneal and thoracic surgical procedures, familiarity with major lymphatic structures, such as including the cisterna chyli (CC) and thoracic duct (TD), has proven beneficial in avoiding misdiagnosis and iatrogenic intraoperative injury. In this light, the aim of our study was to explore and delineate the topography of the CC, classify the different patterns of lymphatic tributaries, and categorize its varying location with respect to the vertebral bodies. The anatomy of the CC was examined in 120 adult human cadavers. The CC was found in 83.3% of the specimens and both the tributaries of the CC and the location, with respect to vertebral level, demonstrated wide variation. The results were classified into four types. The most common tributary configuration (type I), found in 45% specimens, was a single CC formed by the union of the left lumbar trunk (LT) and the intestinal trunk (IT). In 30% the CC was formed where the IT opened into the TD and the right lumbar trunk (RT), LT, retroaortic nodes (RN) and branches from the intercostal lymphatics (IL) joined variably (type II). In 20% the CC was formed by the junction of the RT and IT (type III), while in 5% there was a variable confluence pattern of lymphatic trunks that could not be classified (type IV). The CC was located at L1-L2 (type A) in 63%, T12-L1 (type B) in 21%, T11-T12 (type C) in 8%, T10-11 (type D) in 5%, and T9-10 (Type E) in 3%, of the specimens. The CC was found in the retrocrural space and, in 75% of the cases, to the right of the abdominal aorta. We hope that the data supplied by this study will provide useful information in the future to anatomists, radiologists and surgeons alike.

Chylothorax After Internal Thoracic Artery Harvest

Chylothorax is a rare complication following coronary artery bypass graft surgery. We report a case of chylothorax that complicated a left internal thoracic artery harvest and review the literature regarding this subject.

Bilateral thoracic ducts with coexistent persistent left superior vena cava

A case of bilateral thoracic ducts with coexistent persistent left superior vena cava (SVC) was identified in a 77-year-old Japanese female cadaver during dissection in a gross anatomy course. The persistent left SVC began at the lower surface of the left brachiocephalic vein, descended in front of the aortic arch, and drained into the right atrium through the coronary sinus. The right SVC was normal both in size and in position. The azygos vein, receiving the hemiazygos vein, opened into the right SVC. The accessory hemiazygos vein and the left superior intercostal vein united to form a common trunk, which drained into the left SVC. The left and right thoracic ducts began at the level of the 1st lumbar vertebra, ran upwards parallel and anterior to the vertebral column, and terminated at the venous angles of their corresponding sides. There was an anastomotic branch between them. The present case was considered to be very rare, since the persistent left SVC and bilateral thoracic ducts coexisted. The embryologic basis and clinical importance of this case are discussed.

Thoracic duct tributaries from intrathoracic organs

BACKGROUND

The thoracic duct (TD) is the main collecting vessel of the lymphatic system. Little is known about the intrathoracic tributaries of the TD, which are named intercostal, mediastinal, and bronchomediastinal trunks. The purpose of the study was to identify the lymphatic tributaries from intrathoracic organs to the thoracic duct.

METHODS

The study was performed on 530 adult cadavers. The lymphatics of different organs were catheterized and injected with a dye: lungs (n = 360), heart (n = 90), esophagus (n = 50), and diaphragm (n = 30). The lymphatic tributaries draining the lymph from these organs to the thoracic duct were dissected along their course to the thoracic duct and classified.

RESULTS

The TD tributaries were observed in 147 cases: right lung (n = 46), left lung (n = 69), heart (n = 8), esophagus (n = 13), and diaphragm (n = 11). Connections with the TD were observed at its origin (n = 13), within the mediastinum (n = 87), and at the level of the TD arch (n = 47). Tributaries from the lung issued from lower paratracheal nodes 4 R (n = 14) and 4 L (n = 31), subaortic 5 (n = 4), subcarinal 7 (n = 18), pulmonary ligament 9 (n = 7), upper tracheal 2 L (n = 28), paraortic 6 (n = 11), and celiac nodes (n = 2). Tributaries from the heart connected with the TD in the mediastinum in 1 case (4 L) and with the TD arch in 7 cases. Tributaries from the esophagus connected with the thoracic duct within the mediastinum in 13 cases; anodal routes were frequent (n = 5). The TD tributaries from the diaphragm were observed in 11 cases, always connecting with the TD at its origin.

CONCLUSIONS

Injection of intrathoracic organs permits visualization of TD tributaries. These tributaries appear located at unchanging levels. Lymph of intrathoracic organs may thus drain into the general circulation through the TD. The tributaries may represent a potential route for tumor cells dissemination. When incompetent, due to valve insufficiency, they permit chylous lymph to backflow into the intrathoracic lymph nodes. Injury at this level may lead to intrathoracic chylous effusions.

Management of thoracic duct injuries after oesophagectomy

BACKGROUND

Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment.

METHODS

The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available.

RESULTS

Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50-82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10-16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax.

CONCLUSION

The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails.

The effect of neck dissection on human fat transport

This study examines the effect of neck dissection and thoracic duct ligation on lipid metabolism. Included were 23 patients undergoing neck dissection with thoracic duct ligation. The results showed a temporary reduction in lipid metabolism in approximately half the patients who had a left neck dissection. This effect subsided within 6 months, possibly because of the development of alternative lymph channels. The reduction in fat metabolism in selected cases may have therapeutic effects on patients with morbid hypertriglyceridemia or those who receive chemopreventive regimens. To the best of our knowledge, no similar studies have been reported heretofore in humans.

Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax

BACKGROUND

Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy.

METHODS

We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis.

RESULTS

There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation.

CONCLUSIONS

Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.

Chylopericardium of neoplastic aetiology

Here we present the case of a 30-year-old man diagnosed with a dysgerminoma with mediastinal involvement, who developed an isolated chylopericardium during treatment. The purpose of this paper is to review the etiology, diagnosis and new approaches to the treatment of chylopericardium.

Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study

PURPOSE

To assess the feasibility of percutaneous transabdominal puncture and catheterization of the cisterna chyli or lymphatic ducts (PTCLD) in patients with postoperative chyloperitoneum and chylothorax, and to identify and possibly embolize the chylous fistula.

MATERIALS AND METHODS

Five patients had postoperative uncontrolled chyle fistulas. Two patients with chylothorax had thoracic duct (TD) ligation after esophagectomy and neck surgery. The other three patients had chylous ascites after surgery of the pancreas, the aorta, and the esophagus, respectively. After lymphographic opacification, the cisterna chyli (CC) or retroperitoneal lymph ducts were punctured transabdominally with a 21-gauge needle and catheterized with a 3-F catheter to reach the TD if possible. Microcoils were used to embolize a TD laceration.

RESULTS

Lymph ducts as small as 2-3 mm were catheterized successfully in three patients. The TD was catheterized in two patients; one TD fistula was embolized with cure of chylothorax. In one patient with a surgically tied TD, duct occlusion was confirmed despite continued pleural effusion. Three fistulas, not seen with lymphography, were identified in two of three chylous ascites and one chylothorax. There was no morbidity. As a result of this procedure, four of five patients did not require repeated operation.

CONCLUSIONS

PTCLD in the study of chyle fistulas was feasible and safe in the management of five patients and clinically useful in four patients; transabdominal catheter lymphography with aqueous contrast medium is more sensitive than pedal lymphography. Further evaluation is necessary.

Percutaneous transabdominal embolization of thoracic duct lacerations in animals

PURPOSE

To develop percutaneous techniques for lacerating the thoracic duct (TD) and to assess the efficacy of percutaneous TD embolization.

MATERIALS AND METHODS

The TD was catheterized by means of antegrade or antegrade-retrograde techniques after the lymphographically opacified cisterna chyli (CC) was punctured in five swine and one dog. The TD was lacerated by fluid overdistention (n = 1), perforated with stiff guide wires (n = 3) or a 5-F styletted catheter (n = 1), or macerated by rotational guide-wire trauma (n = 1). The TD was percutaneously embolized in five animals with steel (n = 2) and platinum (n = 3) coils. The CC containing a metal target was recatheterized 2-7 days after embolization.

RESULTS

All types of TD trauma led to mediastinal extravasation. The one chylothorax was induced by the 5-F styletted catheter. The TD of four animals was promptly thrombosed with coils. In the fifth animal, the TD failed to thrombose 3 days after embolization, probably because of the use of an undersized platinum are coil. There were no immediate or delayed complications. Necropsy in five animals was unremarkable. The sixth animal was alive and well at 4 months.

CONCLUSIONS

Percutaneous transcatheter TD trauma led to mediastinal extravasation in all six animals, but chylothorax occurred in only one animal. TD coil embolization led to duct thrombosis in four of five animals with no early or late complications. The technique has potential clinical applications for localization and selective embolization of TD leaks in debilitated patients.

Chylothorax after endoscopic sympathectomy: case report

Endoscopic sympathectomy is a new trend for the treatment of hyperhidrosis palmaris. It is a simple and effective technique; however, it carries some recognized risks such as Horner's syndrome and pneumohemothorax. We recently encountered a case complicated by the development of a chylothorax. The patient was a 23-year-old healthy women with profuse palmar sweating. She developed an intractable dry cough after a transthoracic endoscopic sympathectomy. A chest x-ray revealed a left pleural effusion. A chylous effusion was found after thoracentesis and fluid analysis. The pleural effusion resolved after chest tube drainage and diet control. Although endoscopic sympathectomy is a simple and quick procedure, unusual complications, such as chylothorax, may occur. Appropriate early recognition and treatment can prevent a disastrous result.

Chylopericardium and chylothorax, resulting from a catheter to the left subclavian vein: an autopsy report

A 47-year-old woman with long-standing myelofibrosis and thrombocytosis whose spleen was removed 9 days prior to death, died of a heart tamponade. Subsequent autopsy revealed the development of chylothorax and chylopericardium due to the existence of a thrombus obstructing the ostium of the left thoracic duct, as a consequence of the particular location of a central venous catheter in the left subclavian vein in the proximity of the confluence of the left thoracic duct in the afore-mentioned vein.

Successful treatment of chylothorax and superior vena cava obstruction by radiotherapy

Images

Postpneumonectomy tension chylothorax

Chylous leak from the thoracic duct into the pleural space may occur after any type of thoracic surgery. This is a serious, often life-threatening entity. Two cases of postpneumonectomy chylothorax with hemodynamic compromise are reported. Early recognition, pathophysiology, and optimal management of this problem are discussed.

Factors involved in chylothorax following repair of congenital posterolateral diaphragmatic hernia

Chylothorax after repair of congenital posterolateral diaphragmatic hernia has only been reported four times. We add a fifth case and have analyzed these five cases. In all five, the hernia was left sided and a sac was present that was excised. The chylothorax was always left sided. Chylous ascites did not occur. All cases responded to continuous chest drainage without surgical intervention on the thoracic duct or cysterna chyli. All five cases survived.

Chylothorax after myocardial revascularization with internal mammary graft

Chylothorax following an intrapericardial cardiac operation is rare, and we are aware of only 12 reported cases. Nine followed median sternotomy for treatment of congenital heart disorders or acquired valvular disease; more than expected were reoperations (23%). This report documents that this complication may also occur following myocardial revascularization with internal mammary graft and describes the anatomy that makes this possible. This rare complication is important because of the high morbidity of prolonged tube drainage and the fact that nearly half of the affected patients underwent reoperation (5 of 13). Dilated lymphatics exuding chyle have been found at operations undertaken to control lymph fistulas and were located in anterior thymic tissue previously divided by electrocautery. Awareness of the significance of lymph encountered during cardiac operations, particularly during reoperation and near the origin of the internal mammary artery, may alert the surgeon that the stage is set for a disabling complication. Electrocautery may be an unreliable means of control as lymph contains little coagulable material; suture is recommended instead.

Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula

Spontaneous closure of a chylous fistula is usual, but the rare intractable fistula may lead to disastrous nutritional and immunological consequences. We report the surgical management of 5 patients with intractable fistulas with daily drainage averaging 2,060 ml. Conservative therapy failing, the 5 patients underwent 6 ligations of the thoracic duct. A limited posterolateral thoracotomy was used in 3, full right thoracotomy in 2, and left thoracotomy in 1. Ligations were carried out immediately above the diaphragm, and not at the fistula site, by a mass ligature technique encircling all tissue between the azygos vein and aorta. The ligation achieved immediate cessation of drainage in four of five initial procedures and in the fifth patient, at a second operation. High-output thoracic duct fistulas may be handled by supradiphragmatic ligation of the thoracic duct. Identification of the fistula site or the dissection of the thoracic duct itself is avoided by this technique.

Management of nontraumatic chylothorax

Twenty-two patients with chylothorax have been treated at the National Institutes of Health since 1955. In 9 of these patients, the condition resulted from an antecedent operation and in 13, it occurred without a history of prior operation (nontraumatic). All 6 of the patients with tumors in whom nontraumatic chylothorax developed had a lymphoma. Four of these 6 also had a chylous ascites, while 6 of the 7 patients without tumors had an associated chylous ascites. Only 3 of the 13 patients with nontraumatic chylothorax responded to nonoperative therapy alone with stabilization of the pleural effusions. A single patient with systemic lupus erythematosus responded to steroid therapy. In contrast, 3 of 4 patients who underwent thoracotomy for nontraumatic chylothorax had permanent relief of their chylous pleural effusions. In the absence of medically treatable disease, thoracotomy with ligation of the thoracic duct and/or pleurectomy or pleurodesis can provide substantial palliation for patients with nontraumatic chylothorax, even when a discrete source of lymph leakage cannot be localized or ascites is present. Early surgical therapy of nontraumatic chylothorax is advocated in such circumstances.

Pressure measurements in the cervical portion of the thoracic duct in man

Pressures were measured in the cervical portion of the thoracic duct during a surgical procedure performed to drain lymph in 8 male patients. Cyclic variations depending on respiration were observed. Smaller oscillations in pressure were synchronous with the pulse-rate and result from rhythmic compression of the thoracic duct by the aorta in the thorax. In 2 patients the recordings showed superimposed pressure waves which were independent of breathing and the heart-rate and which are thought to be due to spontaneous contractile activity of the duct.

Thoracic duct terminating on the right side associated with aberrant retro-oesophagal right subclavian artery and truncus bicaroticus

A case is described showing the following rare combination of anomalies: (a) the thoracic duct terminating on the right side at the junction of the internal jugular and subclavian veins; (b) the right subclavian artery arising as the last branch of the aortic arch, beyond the left subclavian artery, and passing behind the oesophagus on its way to the upper limb; and (c) the right and left common carotid arteries arising by a common stem (`truncus bicaroticus') from the aortic arch. The literature on the subject is reviewed and the embryological basis for the development of these variations is discussed briefly. It is suggested that special attention be directed to the course of the thoracic duct whenever an anomaly of the branches of the aortic arch is observed.