Correction of complete thoracic duct obstruction with lymphovenous bypass: A case report

Abstract

Thoracic duct injury can be a devastating injury with disruption of lymphatic flow leading to potentially chylothorax and/or severe lymphedema. Standard treatment modalities include thoracic duct ligation or embolization for chylothorax, but treatment options to date are few for resultant lymphedema. In this case report, we describe lymphaticovenous bypass of the thoracic duct to the jugular venous system in a 21-year-old male with secondary lymphedema after iatrogenic thoracic duct injury. The patient experienced improvement of lymphedema symptoms including decreased weight and limb girth as well as normalization of serum markers indicating improved lymphatic delivery to the venous system. Lymphangiogram at 3 months post op demonstrated patency of the lymphaticovenous anastomoses. At 6-month follow-up, the patient had returned to his preoperative level of activity and showed continued improvement of his lymphedema symptoms. Lymphovenous bypass of the thoracic duct may be an effective technique to treat secondary lymphedema from thoracic duct obstruction, though further studies are required to determine long-term efficacy.

Lymphovenous Anastomosis for the Treatment of Thoracic Duct Lesion

“…In the study by Miller et al, 16 a 21-year-old patient presented with generalized lymphedema due to an obstruction of the TD after implantation and explantation of vagal nerve stimulator. He received scar lysis, end-to-end anastomosis of the TD and external jugular vein, and endto-side anastomosis of a lymphatic vessel and internal jugular vein.…”

Thoracic Duct Lymphovenous Bypass: A Preliminary Case Series, Surgical Techniques, and Expected Physiologic Outcomes

“…Microsurgical thoracic duct lymphovenous bypass is indicated in patients with mechanical thoracic duct obstruction at the level of the neck above the clavicle on imaging whose conservative medical and procedural therapies have failed. 8,9,11 In such cases, microsurgery may alleviate symptoms or completely cure them. In collaboration with our interventional radiology colleagues and utilizing our management algorithm, we presented the largest series of thoracic duct lymphovenous bypass to date.…”

Lymphaticovenous anastomosis of the caudal thoracic duct to an intercostal vein: A canine cadaver study

“…[8][9][10] While these procedures generally involve the use of the distal limb lymphatics, anastomosis of the TD to various central veins has also been shown to be an effective treatment option for a range of thoracic conditions. Several recent case studies have documented either end-to-end or end-to-side anastomosis of the TD with the azygos, 11 external jugular, 12 or other local vein, 10 with long-term patency and no change in lipid metabolism, providing evidence that direct anastomosis of the TD to the central venous circulation is effective with minimal side effects. Most of these lymphaticovenous anastomoses are currently performed by using hand-suturing techniques, 8,9,13 despite microvascular anastomotic couplers (MAC) being wellestablished for use with end-to-end or end-to-side anastomoses.…”

“…Most of these lymphaticovenous anastomoses are currently performed by using hand-suturing techniques, 8,9,13 despite microvascular anastomotic couplers (MAC) being wellestablished for use with end-to-end or end-to-side anastomoses. 12 Microvascular couplers have excellent long-term patency and are technically easier and faster to apply than hand-sutured anastomoses, with diameters ranging from 1 to 4 mm, increasing in 0.5 mm increments. [14][15][16] The objective of this study was to describe a surgical technique for end-to-end anastomosis of the caudal thoracic duct to an intercostal vein using a MAC in the dog.…”

“…Several recent case studies have documented either end‐to‐end or end‐to‐side anastomosis of the TD with the azygos, 11 external jugular, 12 or other local vein, 10 with long‐term patency and no change in lipid metabolism, providing evidence that direct anastomosis of the TD to the central venous circulation is effective with minimal side effects. Most of these lymphaticovenous anastomoses are currently performed by using hand‐suturing techniques, 8,9,13 despite microvascular anastomotic couplers (MAC) being well‐established for use with end‐to‐end or end‐to‐side anastomoses 12 . Microvascular couplers have excellent long‐term patency and are technically easier and faster to apply than hand‐sutured anastomoses, with diameters ranging from 1 to 4 mm, increasing in 0.5 mm increments 14‐16 …”