Lymphatics of the Mediastinum, Esophagus and Lungs: Thoracic Surgeon's Point of View

Abstract

Main TextThere are still many points in lymphatic embryology and anatomy to discover because of the limitation of exploratory methods that are available. The lymphatic vascular system is very complex and it hasn't been studied like the blood vascular system.There are different lymphatic drainage pathways in the thorax that are relevant in the staging of thoracic malignancies: lung cancer, esophageal cancer, malignant mesothelioma, lymphomas and breast cancer. Each structure from which a thoracic primary tumor originates has a specific lymphatic spread that has to be known in order to be able to evaluate the spreading of the disease [1]. All these pathways are interconnected with each other and with the thoracic duct.There are three main lymphatic ascendant pathways or lymph node chains described [2]: 1) posterior parietal chain that ascends along the vertebral column in the posterior mediastinum; 2) anterior parietal chain along the internal mammary vessels, and 3) median visceral chain along the esophagus, tracheobronchial tree and phrenic nerves There is also a diaphragmatic lymphatic network which drains the diaphragm and establishes connections with above mentioned chains. The thoracic duct is the main lymphatic vessel in which all other lymphatic networks finally drains.The posterior parietal chain ascends in the posterior mediastinum along the vertebral column and it gathers intercostal lymphatics which drain the chest wall, the posterior pleura and the posterior part of the diaphragm. On their course there are lymph nodes situated in the extrapleural fat adjacent to the rib heads. The drainage of this chain (both sides) is essentially ascendant, finishing in the thoracic duct or directly into the Pirogoff angle. They may also drain inferiorly and involve in this case the limphatics within the gastro-hepatic ligament and celiac nodes.The anterior thoracic chain ascends along the internal mammary vessels and drains the anterior chest wall, the anterior and lateral diaphragm and the medial breast. The internal mammary nodes are found in the intercostals spaces along the sternum and are usually present from the fifth intercostals space to the clavicles [1]. This chain, like the posterior one, can also drain inferiorly through the rectus abdomen's muscle sheath to the sub diaphragmatic and sub peritoneal plexus and forward to the liver and retroperitoneal nodes. There are also connections between left and right anterior thoracic chains.Both posterior and anterior chains, on the left and on the right side, communicate with the median visceral chain and also with each other by intercostals chains.The median visceral chain is actually represented by lymphatics of intrathoracic organs and within the mediastinum. This median visceral chain gathers together a posterior para-esophageal chain, an anterior chain along the phrenic nerves and the most important, a median tracheobronchial chain that drains essentially the lung, but also the heart and the esophagus, better known by surgeons through the TNM classification u...

Comparative Study of Early Postoperative Complications: Thoracic Anastomosis vs Cervical Anastomosis - in Esophageal Replacement with Gastric Graft

“…necessary means and many of the cases were in an advanced stage disease which would have made the minimally-invasive approach even more difficult. No matter which approach is used, open surgery or minimally-invasive surgery, we believe extensive lymphadenectomy in cervical, abdominal and thoracic regions is extremely important especially from a staging point of view but also for better local disease control (7,8). This constitutes the main reason why we prefer to perform a thoracic anastomosis (by open surgery or minimally-invasive surgery) instead of using the Sloan-Orringer technique.…”