A radio‐anatomical correlation study of the cisterna chyli

Abstract

Surgical laparoscopic procedures in the retroperitoneal and supramesocolic spaces are increasingly frequent. There is a high risk of iatrogenic intraoperative injury of the retroperitoneal lymphatic structures during these procedures. A precise understanding of the anatomy of the thoracic duct (TD) and the cisterna chyli (CC) is essential for safe surgical procedures in this area. However, routine imaging procedures rarely and often incorrectly visualize the CC. The objective of this study was to evaluate the feasibility of a retrograde injection of the TD to fill the CC with a contrast agent in 16 human cadavers. Both magnetic resonance lymphography (MRI) and computed tomography (CT) studies could be performed on the same anatomical specimen, using a contrast medium which hardened, allowing gross dissection. MRI and CT detectability were evaluated, and imaging results were compared with the anatomical dissection. The CC of 12/16 cadavers were successfully injected, and four were unsuccessful due to technical difficulties, showing the effectiveness of the method. This technique can improve understanding of the anatomy of the TD and CC and provides an original option to study the complex anatomy of these structures by correlating precise cadaveric dissections with cross-sectional imaging.

Call for a Multidisciplinary Effort to Map the Lymphatic System with Advanced Medical Imaging Techniques: A Review of the Literature and Suggestions for Future Anatomical Research

“…As opposed to the earlier claims that the retrograde injection of lymphatics is not feasible, a recent study by Renard et al proves quite the opposite (Renard et al 2018a). By using a contrast agent for both CT and MRI imaging, a retrograde filling of the cisterna chyli was achieved.…”

“…Even though the smallest of lymphatic vessels may not be suitable for retrograde injection, there is still a wealth of anatomical information to be gained by even visualizing the big‐ to medium‐sized lymphatic vessels in the entire body. On top of that, the contrast agent to achieve this purpose already seems to be readily available (Renard et al , b). As an added bonus, the use of barium sulfate as a contrast agent was even shown to be compatible with micro CT imaging (Blery et al ; Kingston et al ) and the compound is nontoxic (Kingston et al ).…”

“…After surgery, this can cause chylous ascites, the leakage of lymph/chyle (fat metabolite‐rich lymph collected from the small intestine (Akcali et al )), in these cavities. Chylous ascites can cause severe complications like a disruption of immunologic function, malnutrition, septic complications, neurasthenia, dehydration and metabolic acidosis, leading to prolonged hospital stays after surgery (Weniger et al ; Wu et al ; Renard et al ).…”

“…By using the radiopaque contrast agent from Suami et al or Renard et al and by attempting a retrograde injection technique to limit structural damage to the body (avoiding a big dissection field to identify all distal lymphatics for antegrade injection) before scanning, this problem can theoretically be solved. Even though it was argued that retrograde injections of the lymphatic system are not possible (Suami et al ), it should be noted that Suami et al are referring to lymphatic precollectors and it was recently demonstrated that the retrograde injection of the thoracic duct enabled the retrograde filling of the cisterna chyli (Renard et al ). This would imply that the possibility of a retrograde lymphatic injection technique likely depends on the size of the lymphatic vessel to be injected.…”

The use of Thiel embalmed human cadavers for retrograde injection and visualization of the lymphatic system

“…Indeed, in recent years, several papers have been published on mapping the lymphatic system by means of cadaveric dissection and medical imaging approaches. This renewed research interest in the lymphatic system has sparked a search for new possible contrast agents that are able to visualize the lymphatics, both in the cadaveric specimen, as well as on medical imaging modalities (Renard et al, ; Renard et al, ; Shinaoka et al, ; Suami, Taylor, O'Neill, & Pan, ; Suami, Taylor, & Pan, ). For the purpose of radiotherapy planning, which is routinely done on CT scans of the patient, it was decided to focus on CT imaging for this study to map the lymphatics.…”