The right lymphatic duct: basic anatomy and clinical relevance.

The anatomical variability of the thoracic duct and the right lymphatic duct predisposes them to inadvertent damage following head and neck surgery thereby leading to chyle leak which is an uncommon complication with potentially significant associated morbidity. Although chyle leak is predominately associated with left-sided neck surgery, it also occurs as a complication of the right-sided neck dissection. Variable figures concerning chyle leakage after right-sided neck dissections were reported, ranging from 0 per cent to higher prevalences such as 14%, 24%, 33% and 60% of total cases of chyle leakages associated with neck surgery. The right-sided complications may implicate the right lymphatic duct and right-sided terminations of the thoracic duct into the venous system which occur in about 1-6% of humans. Other clinically relevant conditions involving the right-sided major lymphatic vessels include chyle leaks following right anterior cervical spine surgery, cysts of the right lymphatic duct and dilatation of the right lymphatic duct in the setting of recurrent cervical swelling. This article presents a review of the literature concerning the basic anatomy and the clinical relevance of the right lymphatic duct and the right-sided terminations of the thoracic duct into the venous circulation.

Sonography for assessment of thoracic duct anatomy and physiology before and after meals.

The interest in clinical anatomy of the thoracic duct (TD) has recently grown, owing to discoveries linking its morphology to pathologies such as heart failure or liver cirrhosis. In the light of this knowledge, a cost-efficient and reliable in-vivo imaging method of TD should be devised. Ultrasonography satisfies these criteria and hence is a promising tool for assessment of TD's anatomy and function. Thirty-one healthy volunteers attended the examination after 6 h of fasting and 2 h without drink. Ultrasound of the left supraclavicular fossa was performed in search of TD's orifice into the venous angle. In each case, the largest diameter, number of orifices, presence of valves, tributaries, and motility of the TD were examined. We performed examinations in three sessions: after fasting, after standardized meal and 1 h after the meal. The statistical significance has varied among the three sessions. The strongest connection was shown in the third examination. The TD was visualized in 31 cases, 35 orifices were found, most of which drained into the venous angle. Multiple orifices were seen in four cases and valves in 15 cases. Tributaries were present in 17 cases. Mean widest and orifice diameter measured 3.23 and 2.0 mm, respectively. Spontaneous peristaltic-like movements of the TD were observed in 25 cases. We demonstrated that ultrasound is useful for assessment of TD's anatomy, allowing to visualize and quantify its key features. Moreover, our study is presumably the first to capture and describe TD's motility in vivo.

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.

Lymphatic Pathways of the Thorax: Predictable Patterns of Spread.

OBJECTIVE. This article reviews thoracic lymphatic pathways and tributaries, discusses lymphatic anatomic variants and their clinical implications, and emphasizes common patterns of thoracic lymphadenopathy from extrapulmonary malignancies. CONCLUSION. Recognition of common patterns and pathways of thoracic lymphatic drainage can help identify the site of tumor origin and allow a more focused examination of disease extent, both of which are important for disease prognosis and management.

Management options for post-esophagectomy chylothorax.

Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.

Anatomical study of the thoracic duct and its clinical implications in thoracic and pediatric surgery, a 70 cases cadaveric study.

INTRODUCTION: Given the high variability and fragility of the thoracic duct, good knowledge of its anatomy is essential for its repair or to prevent iatrogenic postoperative chylothorax. The objective of this study was to define a site where the thoracic duct is consistently found for its ligation. The second objective was to define an anatomically safe surgical pathway to prevent iatrogenic chylothorax in surgery for aortic arch anomalies with vascular ring, through better knowledge of the anatomical relationships of the thoracic duct. METHODS: Seventy adult formalin-fixed cadavers were dissected. The anatomical relationships of the thoracic duct were reported at the postero-inferior mediastinum, at levels T3 and T4. RESULTS: The thoracic duct was consistently situated between the left anterolateral border of the azygos vein and the right border of the aorta between levels T9 and T10, whether it was simple, double, or plexiform. It was located medially, anteromedially, or posteriorly to the left subclavian artery in 51%, 21%, and 28% of the cases, respectively, at the level of T3. At T4, it was posteromedial in 27% of the cases or had no direct relationship with the aortic arch. CONCLUSION: These results favor mass ligation of the thoracic duct at levels T9-T10 between the right border of the aorta and the azygos vein, eventually including the latter. To prevent iatrogenic postoperative chylothorax in aortic arch anomalies with vascular ring surgery, we recommend remaining strictly lateral to the left subclavian artery at the level of T3 to reach the aortic arch anomalies with vascular ring at T4.

Anatomy of the lymphovenous valve of the thoracic duct in humans.

The majority of lymph generated in the body is returned to the blood circulation via the lymphovenous junction (LVJ) of the thoracic duct (TD). A lymphovenous valve (LVV) is thought to guard this junction by regulating the flow of lymph to the veins and preventing blood from entering the lymphatic system. Despite these important functions, the morphology and mechanism of this valve remains unclear. The aim of this study was to investigate the anatomy of the LVV of the TD. To do this, the TD and the great veins of the left side of the neck were harvested from 16 human cadavers. The LVJs from 12 cadavers were successfully identified and examined macroscopically, microscopically, and using microcomputed tomography. In many specimens, the TD branched before entering the veins. Thus, from 12 cadavers, 21 LVJs were examined. Valves were present at 71% of LVJs (15/21) and were absent in the remainder. The LVV, when present, was typically a bicuspid semilunar valve, although the relative size and position of its cusps were variable. Microscopically, the valve cusps comprised luminal extensions of endothelium with a thin core of collagenous extracellular matrix. This study clearly demonstrated the morphology of the human LVV. This valve may prevent blood from entering the lymphatic system, but its variability and frequent absence calls into question its utility. Further structural and functional studies are required to better define the role of the LVV in health and disease.

Anatomical variations in distal portion of the thoracic duct-A systematic review.

The objective of this study was to identify and analyze the anatomical variations in the termination of the thoracic duct (TD) in cadavers or patients by anatomical dissections and surgical or radiological procedures for better knowledge of the interindividual variations through a systematic review. The search strategy included PubMed and reference tracking. Studies were identified by searching the electronic Medline databases. The search terms included "TD," "Jugular Vein," "Subclavian Vein," or "Cervical," and the protocol used is reported herein. These search results yielded 20 qualitative review articles out of the 275 articles consulted. We collected all the important data from these 20 articles with 1,352 TD analyzed by varying sources in our search. Regarding the characteristics of the studies and the anatomy of the TD, the results were heterogeneous. The TD most commonly terminates in the internal jugular vein in 54.05% of cases (95% confidence interval [CI]: 54.03; 54.07), in the jugular-venous angle in 25.79% (95% CI: 25.77; 25.81), and in the subclavian vein in 8.16% of cases (95% CI: 8.14;8.18). Other terminations were found in 12% of cases. This systematic review provided an overview of the variations in the distal portion of the TD. This study can be helpful for surgeons in selecting the most appropriate methods to achieve successful surgical results and avoid complications, such as chylothorax; it also offers detailed information on the cervical termination of the TD in new diagnostic and therapeutic methods involving the TD. Clin. Anat. 32:99-107, 2019. © 2019 Wiley Periodicals, Inc.

A radio-anatomical correlation study of the cisterna chyli.

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.

Magnetic resonance thoracic ductography assessment of serial changes in the thoracic duct after the intake of a fatty meal.

The thoracic duct, a terminal lymph vessel, is thought to dilate after the intake of a fatty meal. However, this physiological change has not been well explored in vivo. Therefore, the present study aimed to assess serial changes in the thoracic duct after the intake of a fatty meal using magnetic resonance thoracic ductography (MRTD). Eight healthy volunteers were subjected to one MRTD scan before a fatty meal and eight serial MRTD scans every hour thereafter. The cross-sectional areas of the thoracic duct were estimated using MRTD measurements of the diameters of the thoracic duct at the upper edge of the aortic arch, the tracheal bifurcation, the mid-point between the tracheal bifurcation and the left part of the diaphragm and the left part of the diaphragm. The change-rates in these areas were calculated before and after the fatty meal intake, and the maximal change-rate and timing of its achievement were determined for each subject. The summed change-rates in the four portions of the thoracic duct ranged from -40.1 to 81.3%, with maximal change-rates for each subject ranging from 22.8 to 81.3% (mean, 50.4%). Although individual variations were observed, most subjects (88.9%) exhibited a maximal change-rate at 4-6 h after meal intake, with subsequent decreases at 7-8 h. In conclusion, MRTD revealed a tendency toward thoracic duct enlargement at 4-6 h after the intake of a fatty meal, followed by contraction.

The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: potential implications for intervention.

The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108 years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.

Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum.

BACKGROUND: The structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues. METHODS: Semi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues. RESULTS: The "visceral sheath" and "vascular sheath," as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the "visceral sheath" on the right side of the upper mediastinum was unclear in comparison to the left side. The "visceral sheath" (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the "visceral sheath" in all cadavers, the left recurrent nerve lymph nodes were located inside the "visceral sheath" in cadaver 1 and between the "visceral sheath" and "vascular sheath" in cadaver 3. CONCLUSION: The "visceral sheath" around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.

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

UNLABELLED: 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.

Anatomical Variations of the Thoracic Duct: A Preliminary Report in Adult and Fetal Specimens.

The study aim is to evaluate anatomical variations of the thoracic duct using a specialized sequential injection procedure. The different types, frequencies, and anatomical topography were recorded and evaluated using 12 adult and 16 fetus specimens. By employing a perfusion pump device, cadavers were sequentially perfused with acrylic colored latex first through the internal marginal vein, then the thoracic duct at the interazygous-aortic recess, and finally through the posterior tibial artery. After perfusion, thoracic ducts were identified, partially dissected, and cadavers fixed by soaking in an aqueous solution of 5% formalin (v/v). Finally, further dissection and detailed photography were performed. Plexus shapes at different levels were clearly evident in 80% of the adult specimens. Whereas the presence of the cisterna chyli was detected in 100% of fetuses as an ampule dilatation at the beginning of the thoracic duct, in only one adult specimen was a dilatation found at the lumbar lymphatic trunk level. Functionally it is not known whether these modified anatomical features (plexus shapes) have served to compensate (as a derivative pathway) for lymphatic hypertension in life as a reflection of lymphatic system challenges and subsequent growth in the adult specimens.

[Vascular relationships of the right great splanchnic nerve in the thorax]. / Rapports vasculaires thoraciques du nerf grand splanchnique droit.

AIM: The surgical assumption of responsibility of the pancreatic pain requires either a truncular coelioscopic or radicular neurectomy of greater splanchnic nerves (gsn). The goal of our work is to describe the way and relations of the right gsn which are variable and rarely described. This constitutes an undeniable peroperational hemorrhagic risk during splanchnicectomy. MATERIAL AND METHODS: After a double side thoracotomy and a bilateral sterno-clavicular desarticulation on 15 adult cadaveric subjects preserved by method of Winckler we removed the sterno-costal drill plate as well as the ventral rib arch and proceeded to a mediastinal evisceration of the thorax. Then we respected only the thoracic aorta and the oesophagus, the azygos venous system, the thoracic duct and the thoracic sympathetic chain. In some of the subjects, the azygos vein was injected (after catheterization of its stick) using gelatine coloured with blue paint. We studied the way and vascular relations of the right gsn. We measured the transverse distances between the origin of the gsn on one hand and the longitudinal axes of the azygos vein and the thoracic duct on the other hand. RESULTS: The relations of the right gsn trunk during its way related to the azygos vein in particular its constitutive origin and its affluents: ascending lumbar vein and twelfth intercostal vein. Sometimes the thoracic duct even a lymphatic node was near the gsn in the posterior infra-mediastinal space. A classification of the way and vascular relations of the right gsn in the thorax identified 3 anatomical types. The average distances separating the right gsn on one hand from the azygos vein and the thoracic duct on the other hand were respectively 5.7 mm and 11.2 mm. CONCLUSION: The vascular relations of the right gsn are very variable from one subject to another but primarily venous, sometimes lymphatic. They concerned the great thoracic vessels whose respect is essential in particular at the time of mini-invasive access procedure for a cœlioscopic splanchnicectomy.

Review of thoracic duct anatomical variations and clinical implications.

The thoracic duct (TD) transports ingested fat, drains lymph from the gastrointestinal vascular bed, and delivers the lymph to central veins in the neck. Preliminary evidence suggests that diversion of TD lymph may mitigate the severity of end-organ dysfunction in critical illness. Variations in the anatomy of the TD may determine whether reliable and safe cannulation of the duct, a necessary step for diversion, is possible. A systematic review was undertaken using the Google Scholar, MEDLINE, PubMed, and Scopus databases until 31st March, 2013. Both English and non-English articles were searched for, and surgical, cadaveric, and radiologic studies were included. Fifty-seven articles from the past 102 years were retrieved. There are significant variations in the anatomy of the TD in terms of its formation at the cisterna chyli, its course through the thorax, and its termination in the venous system. The most common site of termination is at the internal jugular vein (46%), followed by the jugulosubclavian angle (32%), and the subclavian vein (18%). An improved understanding of the anatomy of the TD would help surgeons to avoid inadvertent injury and potentially afford new opportunities for diagnosis and intervention in patients with critical illness.

Computed tomographic characteristics of the cisterna chyli in dogs.

Previous lymphangiographic studies have investigated the use of computed tomography (CT) for characterizing the thoracic duct and its tributaries in dogs. However, there is limited published information on the appearance of the canine cisterna chyli using CT. The objective of this retrospective study was to describe the features of the canine cisterna chyli in pre- and post-contrast abdominal CT studies. The presence, location, shape, maximum width, size compared with the aortic diameter (Ao:cisterna chyli ratio) and mean attenuation of the cisterna chyli were recorded from archived abdominal CT scans of 30 dogs. Breed, age, sex and neutering status were also noted. A cisterna chyli was identified in 26 of the dogs (87%). In 22 cases a cisterna chyli could be reliably identified prior to intravenous contrast administration and in all 26 cases in postcontrast images. The cisterna chyli was most commonly located right dorsolateral to the abdominal aorta between L1 and L4. Shape varied on transverse images from crescent-like to globular and maximum diameters ranged from 5 to 9 mm. The Ao:cisterna chyli ratio varied between 0.29 and 0.71 (mean value-males: 0.32; females: 0.38). On pre-contrast images the mean Hounsfield units were 21.3HU (range: -3.8 to 64.25). Mild enhancement of the cisterna chyli post-contrast was observed in 24 dogs (80%). Findings supported the use of pre- and post-contrast abdominal CT as a non-invasive method for assessing qualitative and quantitative characteristics of the canine cisterna chyli.

Ultrasonographic characteristics of the cisterna chyli in eight dogs and four cats.

Ultrasonography of the cisterna chyli has been used in humans to diagnose increased lymphatic flow or lymph flow obstruction and to guide percutaneous embolization of the thoracic duct via the cisterna chyli. The aim of this study was to describe the ultrasonographic characteristics of the dorsal portion of cisterna chyli in dogs and cats with chylous ascites or chylothorax and in a group of healthy dogs and cats. The aorta and the cranial mesenteric artery were used as anatomic landmarks. Ultrasonography was performed before and 2 h after a fatty meal in healthy dogs and cats. The visualized structure was confirmed to be a dilated cisterna chyli at necropsy in a dog with chylous ascites. The confirmed or presumed cisterna chyli was consistently detected using ultrasonography in nonfasted healthy animals and clinically affected animals and appeared as an anechoic tubular structure, without detectable flow, at the right dorsolateral aspect of the aorta. It had a similar ultrasonographic appearance in patients with chyloabdomen and in nonfasted healthy dogs and cats. There was considerable overlap in diameters of the cisterna chyli for affected and healthy animals. The shape and size of the cisterna chyli in an individual animal were variable during the same ultrasound examination and between different examinations. This study demonstrated the appearance of the presumed dorsal portion of the cisterna chyli by ultrasonography and might provide useful preliminary data for further studies into the feasibility of ultrasound-guided injections or aspirations of the cisterna chyli in dogs and cats.

Thoracic duct relationships to abnormal neurovascular structures in cervicothoracic regions: case study and clinical relevance.

The presence of variant intercostal and bronchial arteries and variable position of left recurrent laryngeal nerve (LRLN) along the course of thoracic duct (TD) may have clinical relevance in various cervicothoracic surgeries.

[Lesions of the visceral mediastinum]. / Läsionen des viszeralen Mediastinums.

BACKGROUND: The visceral or middle mediastinum contains nonvascular (trachea, carina, esophagus, and lymph nodes) and vascular structures (heart, ascending aorta, aortic arch, descending aorta, superior vena cava, intrapericardial pulmonary arteries, thoracic duct). OBJECTIVES: The various pathologies of the visceral mediastinum and imaging features are presented. MATERIALS AND METHODS: Plain film radiography shows the gross anatomy and allows visualization of larger pathologies. However, for detailed anatomic and structural classification more sophisticated imaging techniques are required. Especially computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) are well suited for structural and functional assessment of mediastinal lesions. CONCLUSION: This article summarizes the major pathologies of the visceral mediastinum.