They are usually asymptomatic or less commonly may present as a left supraclavicular fossa mass 1.. This formation of chylothorax can be the first sign of malignancy. The thoracic duct is … The FocalSeal® or other sealant should be prepared and the cream needs to be ordered pre-operatively. It also impedes inflow to the heart and may lead to decreased blood pressure or arrhythmias. The media is composed of smooth muscle and connective tissue. Usually if an Ivor Lewis has been performed the anastomosis should be above the azygous vein and there still should be lots of redundancy in the conduit. The thoracic duct is particularly vulnerable to trauma during esophageal surgery. The thoracic duct has variant anatomy in ~40% (range 30-50%) of the population 1, 4: Pathology of the thoracic duct is rare but includes: ADVERTISEMENT: Supporters see fewers/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The thoracic duct also contains valves which may be unicuspid, bicuspid, or tricuspid, but are usually bicuspid. [ 21 ]) A common variation is a bifid lower aspect of the trunk caused by embryonic right and left lymphatic trunks failing to fuse. 1973;115 (Pt 1): 45-52. This most commonly occurs after esophagectomy. The thoracic duct displays physiologic adaptation to certain disease processes by increasing in diameter. Chest Surg Clin N Am 1994;4:617-28, Sieczka EM, Harvey JC. Non-pledgeted sutures will tear it further. The adult thoracic duct is derived from both of these embryonic thoracic ducts. Br J Hosp Med 1994;51:482-90, Johnstone DW, Feins RH. Anatomical illustration of the origin, course, and termination of the thoracic duct (Reproduced with permission from Stranding et al. ) It can stain the surrounding tissue and can make finding the leak difficult. Liu ME, Branstetter BF, Whetstone J et-al. 2014 Jul. Use of clips may be an adjunct, but I prefer pledgeted sutures. The leak should be completely stopped. It also has a basement membrane. The thoracic duct enters the thoracic cavity through the aortic hiatus and ascends to the right of the midline in the posterior mediastinum between the aorta and azygos vein, posterior to the esophagus. J Surg Oncol 1996;61:56-60. Chylothorax. Mauro MA, Murphy KP, Thomson KR et-al. Frequent physiologic variants also make avoiding the duct during surgery somewhat difficult. Lymphatic leaks can occur in the neck, in the abdomen, or in either or both chests, and they can be controlled in any of those compartments. Once the diagnosis is secured early intervention is critical. (C) Cone beam CT-guided puncture of the cisterna chyli. 4. The diagnosis is confirmed by a triglyceride level of 110 mg/dl or greater, the presence of chylomicrons in the chest tube drainage, a positive Sudan stain, or, if needed, lipoprotein electrophoresis. (B) Spot radiograph showing the course of the thoracic duct in another patient. A cisterna chyli is present in about half of individuals. The thoracic duct can also terminate as a single vessel (up to 87.5%), bilateral ducts (up to 25%), or several terminal branches (up to 7%). It is also called the left lymphatic duct or the alimentary duct. Frequent physiologic variants also make avoiding the duct during surgery somewhat difficult. These extra precautions add little time or morbidity. Clinical presentation. There may be some drainage of chyle out of the right-sided chest tubes but the gastric conduit obscures a large pleural effusion. Do not give the cream via the jejunostomy tube too early. As a central structure to lymphatic flow and movement, thoracic duct dysfunction and resulting chyle accumulation is concerning for malignancy. The thoracic duct enters the thoracic cavity through the aortic hiatus and ascends to the right of the midline in the posterior mediastinum between the aorta and azygos vein, posterior to … Knowing when to re-operate on any of your own patients is difficult. The thoracic duct is the main lymphatic vessel for the return of chyle/lymph to the systemic venous system. Do not sew the duct without pledgets. The function of the thoracic duct is to transport lymph back into the circulatory system. 6. Recheck the area of the closure. If the leak is high in the chest, simple ligation of the main duct at the level of the hiatus via a laparotomy may not be sufficient and the fistulous effusion may continue. Chest Surg Clin N Am 1996;6:139-48, Hillerdal G. Chylothorax and pseudochylothorax. If one performs a second re-operation on a persistent leak after an attempted repair, especially if the patient’s other operations were performed elsewhere, we strongly recommend a pre-operative lymphangiogram. Unexplained fever, abscess formation, or abnormal fluid collections should raise the suspicion of a thoracic duct … Trunks continue to anastomose and enlarge, forming embryonic right and left thoracic ducts. It is a fibrin-less system that runs in the posterior mediastinum. Another variation is the lower thoracic duct being replaced by a plexus of lymphatic vessels and forming a single duct higher in the mediastinum. multiple ducts) (~20%), aberrant termination: left internal jugular vein, left, multiple terminal channels from a single duct with a typical course (~20%), continues on the right to terminate in the right internal jugular vein, central venous catheter cannulation of the thoracic duct (rare). A right-sided chest drain was placed to evacuate a chylous pleural effusion. There are many anatomic variations of the thoracic duct. Keep sewing until it is bone dry. The definitive thoracic duct is then formed by the cisterna chyli, the lower two thirds of the right lymphatic trunk, and the upper third of the left lymphatic trunk. In its terminal (distal) portion the thoracic duct may be more often flared or dilated rather than continue at a consistent diameter 1. The drainage pattern may play a role in the prognosis of cancers of these organs. The conduit can be easily mobilized off of the posterior mediastinum within 5 – 9 days, exposing the vertebral bodies. A nasogastric tube should be left in or positioned with fluoroscopy into the gastric conduit prior to placing the patient in the left lateral decubitus position. The thoracic duct is 38 to 45 centimeters long and 2 to 5 millimeters in diameter. The typical anatomy described above is present in only about 50% of individuals. Do not settle for a small dribble. Unable to process the form. The thoracic duct carries the mixture of lymph and chyme from the cisterna chyli upward through the thorax … ISBN:B00E6GB08K. Ensure that the anastomosis is not being stretched. Two rare variations include complete bilateral thoracic ducts and termination of the duct into the azygous system. The disadvantages of going on the virginal left side are that you have committed the patient to recover from bilateral thoracotomies and you cannot perform a mechanical pleurodesis to help obliterate the pleural space. This discussion focuses on transthoracic ligation, but the surgeon must decide which chest to enter. Ann Thorac Surg 1993;55:1006-8, Paes ML, Powell H. Chylothorax: an update. When embryologic lymphatic trunks converge above the T12 vertebral level, the cisterna chyli is generally absent, but there may be dilation of lower lumbar trunks. The thoracic duct is the largest lymphatic vessel in the human body that is responsible for the passage of around 75% of the lymph from the whole of the body except the right upper limb, right breast, right lung and right side of the head and neck. A failed procedure and the need for a third operation within 10 days will erode patient and family confidence in you.

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