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PubMed1998

Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound.

BACKGROUND: Thoracic duct dilation has been demonstrated in portal hypertension and hepatic cirrhosis by lymphangiography and laparotomy and at autopsy. It is thought to be secondary to increased hepatic lymph flow and has been described in the absence of ascites or esophageal varices. The aim of the present study was to observe thoracic duct morphology by endoscopic ultrasound in various subsets of patients with portal hypertension and hepatic cirrhosis and also to validate existing radiologic/surgical data. METHODS: The thoracic duct of 33 patients with cirrhosis and portal hypertension was studied by endoscopic ultrasound. Patients were divided into four groups: 1, patients with ascites and esophageal varices; 2, esophageal varices without ascites; 3, without esophageal varices or ascites; 4, extrahepatic portal hypertension due to pancreatic malignancy. The thoracic duct diameter was also measured in 14 control subjects (group 5). RESULTS: When the thoracic duct diameter for the five groups was compared with analysis of variance, significance was p < 0.0001; by pairwise comparison, group 1 differed from the other four groups (p < 0.05). Thoracic duct dilation (5.61 mm) was seen in group 1 patients, whereas no dilation was present in groups 2 through 4. Additionally, thoracic duct diameter in 33 portal hypertensive and/or cirrhotic patients was significantly different from that in the 14 control subjects (p = 0. 003). CONCLUSION: The thoracic duct can be reliably identified by EUS in patients with hepatic cirrhosis and portal hypertension. Dilation of the duct is seen only in patients with hepatic cirrhosis, ascites, and esophageal varices. No thoracic duct dilation is present in extrahepatic portal hypertension. Contrary to existing radiologic/surgical data, thoracic duct dilation is not seen in all patients with hepatic cirrhosis and portal hypertension signifying advanced disease. A dilated thoracic duct by endoscopic ultrasound should be considered yet another sign of portal hypertension.

Ascites↗
PubMed1988

Results of thoracic duct ligation in dogs with chylothorax.

Thoracic duct lymphangiography and ligation were done on 15 dogs with idiopathic chylothorax. Lymphangiography revealed thoracic lymphangiectasia in all dogs; none had a thoracic duct rupture. Lymphangiography immediately after ligation demonstrated missed branches of the thoracic duct in 4 of the 15 dogs. Eleven of the 15 dogs are alive and doing well. Eight of the 11 had no radiographic or clinical signs of pleural effusion (mean follow-up, 31.5 months; range, 4 to 75 months). The other 3 living dogs had persistent effusion; 2 were successfully managed with a pleuroperitoneal shunt (follow-up, 15 months) or pleurodesis (follow-up, 5 months), respectively, and 1 was not treated because the effusion was mild and the dog did not have clinical signs of disease (follow-up, 14 months). Four of the 15 dogs died or were euthanatized because of persistent effusion (mean follow-up, 11.5 months; range, 3 to 24 months). Considering the lack of treatment alternatives for dogs with idiopathic chylothorax, these results support thoracic duct ligation as a treatment method for dogs.

Animals↗
PubMed2003

Thoracic duct cyst of the mediastinum.

Thoracic duct cysts of the mediastinum are extremely rare. The etiology may be related to a congenital or degenerative weakness in the wall of the thoracic duct. They are generally asymptomatic but may sometimes cause pressure effects on adjacent structures. Imaging studies are supportive but not diagnostic. Excision of these cysts is required for diagnosis and to prevent complications. We describe a 49-year old man who presented to us with hoarseness and a fixed right vocal cord. Computed tomography (CT) showed a cystic posterior mediastinal mass in the right paratracheal region. We performed a posterolateral thoracotomy and found the cyst arising from the thoracic duct and contained chylous fluid with a high lipid concentration. We dissected the cyst from the surrounding structures and excised it. Histopathology revealed a cyst lined by a single layer of endothelial cells. He is asymptomatic now one year after surgery.

Humans↗
PubMed1968

Renal contribution to thoracic duct lymph in dogs.

1. The renal contribution to thoracic duct lymph was measured in seventeen anaesthetized fasting dogs by measurement of thoracic duct flow before and after renal arterial occlusion.2. In eight experiments it was shown that thoracic duct flow and glomerular filtration rate were not significantly affected by the operation to expose the renal artery.3. In three experiments occlusion of the renal vein, after release of arterial occlusion, resulted in a sudden increase in thoracic duct flow.4. In animals infused with isotonic saline or dextrose (approximately 1 ml./min) the average values obtained for control thoracic duct flow, left renal flow and right renal flow were approximately 2.0, 0.7 and 0.3 ml./hr/kg body wt.: in non-infused animals these values were 1.4, 0.4 and 0.35 ml./hr/kg body wt. respectively.5. Possible reasons for the apparently smaller lymph flow from the right than the left kidney, and the relationship between the renal contribution to thoracic duct flow and actual renal lymph flow are discussed.6. Close correlation was found between control thoracic duct flow and body weight and between renal lymph flow and control thoracic duct flow.

Animals↗
PubMed2005

Increased lymphatic flow in the thoracic duct during manipulative intervention.

The thoracic pump and the abdominal pump are osteopathic manipulative (OM) lymphatic pump techniques frequently used by osteopathic physicians to treat patients with infections (eg, pneumonia, otitis media). Although there is a widely accepted belief among the osteopathic medical profession that increasing lymphatic flow is beneficial, no measurements of lymph flow during osteopathic manipulative treatment have been reported. The authors surgically instrumented five mongrel dogs to record lymphatic flow in the thoracic duct (TDF) and cardiac variables during three intervention protocols. After recovery from surgery, canine subjects were placed in a standing-support sling, and TDF, cardiac output, mean aortic blood pressure, and heart rate were recorded during two randomized 30-second sessions of manipulative intervention using the osteopathic thoracic pump and abdominal pump techniques on two successive days. Lymph flow in the thoracic duct increased from 1.57+/-0.20 mL x min(-1) to a peak TDF of 4.80+/-1.73 mL x min(-1) during abdominal pump, and from 1.20+/-0.41 mL x min(-1) to 3.45+/-1.61 mL x min(-1) during thoracic pump. Lymph flow in the thoracic duct and cardiac variables were also recorded for canine subjects during physical activity (ie, treadmill exercise at 3 miles per hour at 0% incline). During physical activity, TDF increased from 1.47+/-0.33 mL x min(-1) to 5.81+/-1.30 mL x min(-1). Although cardiac variables did not change significantly during manipulative intervention with lymphatic pump techniques, cardiac output and heart rate did increase during physical activity. The authors conclude that physical activity and manipulative intervention using thoracic pump and abdominal pump techniques produced net increases in TDF (P<.05).

Animals↗
PubMed1968

Cell to cell interaction in the immune response. I. Hemolysin-forming cells in neonatally thymectomized mice reconstituted with thymus or thoracic duct lymphocytes.

An injection of viable thymus or thoracic duct lymphocytes was absolutely essential to enable a normal or near-normal 19S liemolysin-forming cell response in the spleens of neonatally thymectomized mice challenged with sheep erythrocytes. Syngeneic thymus lymphocytes were as effective as thoracic duct lymphocytes in this system and allogeneic or semiallogeneic cells could also reconstitute their hosts. No significant elevation of the response was achieved by giving either bone marrow cells, irradiated thymus or thoracic duct cells, thymus extracts or yeast. Spleen cells from reconstituted mice were exposed to anti-H2 sera directed against either the donor of the thymus or thoracic duct cells, or against the neonatally thymectomized host. Only isoantisera directed against the host could significantly reduce the number of hemolysin-forming cells present in the spleen cell suspensions. It is concluded that these antibody-forming cells are derived, not from the inoculated thymus or thoracic duct lymphocytes, but from the host. Thoracic duct cells from donors specifically immunologically tolerant of sheep erythrocytes had a markedly reduced restorative capacity in neonatally thymectomized recipients challenged with sheep erythrocytes. These results have suggested that there are cell types, in thymus or thoracic duct lymph, with capacities to react specifically with antigen and to induce the differentiation, to antibody-forming cells, of hemolysin-forming cell precursors derived from a separate cell line present in the neonatally thymectomized hosts.

Animals↗
PubMed1981

Late follow-up after thoracic duct drainage in cadaveric renal transplantation.

Thoracic duct drainage was added to conventional immunosuppression with azathioprine, prednisone and, sometimes, antilymphocyte globulin in 83 patients given cadaveric kidneys, including 65 primary graft recipients. The most effective use of thoracic duct drainage was for pretreatment. Optimal conditioning was at least four weeks duration, and when lymph drainage was this long, the incidence of rejection during the first three postoperative months was reduced to 4.5 per cent. Shorter pretreatment or institution of thoracic duct drainage contemporaneous with transplantation were less effective, but the one year results were still better than those with conventional immunosuppression alone. However, the advantage gained with thoracic duct drainage during the first year was diminished in all the treatment groups by graft losses in the second postoperative year. It was concluded that, without better maintenance therapy, the full value of temporary early lymphoid depletion procedures cannot be fully exploited.

Cadaver↗
PubMed1980

Evidence for alpha-adrenergic innervation of the isolated canine thoracic duct.

The excitatory innervation of isolated thoracic duct segments was studied using tissue bath techniques. No spontaneous activity was present in longitudinal or helical strips obtained from a portion of the thoracic duct cephalad to the hilum of the lung. Norepinephrine (10(-8) to 10(-5) M) and tyramine (3 x 10(-5) M) produced contractions that were antagonized by phentolamine (2 x 10(-5) M) and phenoxybenzamine (10(-7) M). Acetylcholine (10(-7) to 10(-4) M) produced contractions that were antagonized by atropine (5 x 10(-9) M). Thoracic duct strips also contracted in response to field electrical stimulation, and maximal responses were obtained with a stimulus of 15 V, 15 Hz, and 1-ms pulse duration. These electrically induced contractions were abolished by tetrodotoxin (5 x 10(-7) M), phentolamine (2 x 10(-5) M), phenoxybenzamine (10(-7) M), and guanethidine (3 x 10(-6) M), but not by atropine (10(-6) M). We conclude that smooth muscle of the canine thoracic duct contains alpha-adrenergic and acetylcholine receptors, both of which cause contraction when stimulated. However, only the alpha-receptors appear to be innervated.

Acetylcholine↗
PubMed1969

Initiation of antibody responses by different classes of lymphocytes. I. Types of thoracic duct lymphocytes involved in primary antibody responses of rats.

Thoracic duct cells and spleen cells were tested for their ability to restore the primary antibody response of X-irradiated rats to bovine serum albumin (BSA), sheep red blood cells (SRBC), horse spleen femtin (HSF), and Salmonella typhi flagella. Spleen cells were at least as efficient as thoracic duct cells in restoring the response to BSA, HSF, and Salmonella typhi flagella. In further experiments thoracic duct cells lacking large dividing lymphocytes were tested for their ability to restore the primary response. Large lymphocytes were eliminated by the in vitro incubation of thoracic duct cells for 24 hr at 37 degrees C or by treatment of thoracic duct cell donors with the mitotic inhibitor vinblastine sulfate 24 hr prior to cannulation of the thoracic duct. Experiments with SRBC show that incubated cells and cells from vinblastine-treated donors are as efficient as normal cells in restoring the primary antibody response. On the other hand, experiments with HSF and Salmonella typhi flagella show that incubated cells and cells from vinblastine-treated donors are about five times less efficient than normal cells in restoring the response. Normal thoracic duct cells were more efficient than incubated cells but less efficient than cells from vinblastine-treated donors in restoring the early response to BSA. The experimental findings indicate that the classes of thoracic duct lymphocytes which initiate the primary antibody response to SRBC differ from the classes which initiate the response to HSF and Salmonella typhi flagella, or BSA.

Agglutination↗
PubMed2003

Anatomic landmarks for the cervical portion of the thoracic duct.

OBJECTIVE: Avoidance of injury to the thoracic duct during neurosurgical procedures involving the cervical region depends on a working knowledge of its location. This study evaluates superficial anatomic landmarks for the cervical portion of the thoracic duct that may be encountered in neurosurgery of the neck. METHODS: Fifteen dissections of human cadavers were performed to study the relationship between the proximal thoracic duct and superficial landmarks (e.g., the cricoid cartilage and sternal notch of the manubrium). RESULTS: The cervical portion of the thoracic duct was found to be approximated by a roughly 4.4-cm(2) region in the left supraclavicular area beginning approximately 2.0 cm lateral to the midline and 3.5 cm superior to the sternal notch, extending superiorly to a point roughly 3.5 cm from the midline and 2.5 cm inferior to the cricoid cartilage, and terminating within the venous system at a point approximately 4.5 cm lateral to the midline and 3.0 cm superior to the sternal notch. CONCLUSION: Through an increased appreciation for its location, injury to the thoracic duct may be minimized.

Aged↗
PubMed2002

Thoracic duct tributaries from intrathoracic organs.

BACKGROUND: The thoracic duct (TD) is the main collecting vessel of the lymphatic system. Little is known about the intrathoracic tributaries of the TD, which are named intercostal, mediastinal, and bronchomediastinal trunks. The purpose of the study was to identify the lymphatic tributaries from intrathoracic organs to the thoracic duct. METHODS: The study was performed on 530 adult cadavers. The lymphatics of different organs were catheterized and injected with a dye: lungs (n = 360), heart (n = 90), esophagus (n = 50), and diaphragm (n = 30). The lymphatic tributaries draining the lymph from these organs to the thoracic duct were dissected along their course to the thoracic duct and classified. RESULTS: The TD tributaries were observed in 147 cases: right lung (n = 46), left lung (n = 69), heart (n = 8), esophagus (n = 13), and diaphragm (n = 11). Connections with the TD were observed at its origin (n = 13), within the mediastinum (n = 87), and at the level of the TD arch (n = 47). Tributaries from the lung issued from lower paratracheal nodes 4 R (n = 14) and 4 L (n = 31), subaortic 5 (n = 4), subcarinal 7 (n = 18), pulmonary ligament 9 (n = 7), upper tracheal 2 L (n = 28), paraortic 6 (n = 11), and celiac nodes (n = 2). Tributaries from the heart connected with the TD in the mediastinum in 1 case (4 L) and with the TD arch in 7 cases. Tributaries from the esophagus connected with the thoracic duct within the mediastinum in 13 cases; anodal routes were frequent (n = 5). The TD tributaries from the diaphragm were observed in 11 cases, always connecting with the TD at its origin. CONCLUSIONS: Injection of intrathoracic organs permits visualization of TD tributaries. These tributaries appear located at unchanging levels. Lymph of intrathoracic organs may thus drain into the general circulation through the TD. The tributaries may represent a potential route for tumor cells dissemination. When incompetent, due to valve insufficiency, they permit chylous lymph to backflow into the intrathoracic lymph nodes. Injury at this level may lead to intrathoracic chylous effusions.

Adult↗
PubMedDate not supplied

Thoracic duct cyst: an unusual supraclavicular mass.

Lesions of the thoracic duct may occur either in the neck or the mediastinum. The majority of lesions that present in the neck consist of chylous fistulae and are secondary to neck surgery. Cysts of the thoracic duct are very rare and are usually reported as a disease entity of the mediastinum. There are only two reported cases in the literature of thoracic duct cysts occurring in the neck. The third case of a thoracic duct cyst located primarily in the neck is reported. Thoracic duct cysts in the neck must be differentiated from other cysts of the neck, because not recognizing the inferior attachment to the thoracic duct, may result in the disastrous consequence of a chylothorax. Diagnosis can easily be made by fine-needle aspiration with biochemical analysis. Computerized axial tomography (CAT) is useful in defining the anatomic boundaries. A weakness in the wall of the thoracic duct, either on a congenital or degenerative basis, has been postulated as the etiology. The natural history of these lesions remains unknown. Smaller lesions may be followed at routine intervals. Larger lesions should be surgically removed because of the possible complications that may ensue as a result of traumatic rupture or inflammation.

Humans↗
PubMedDate not supplied

Thoracoscopic management of thoracic duct injury: Is there a place for conservatism?

Thoracic duct injury is a rare but serious complication following chest surgeries and major neck dissections. Clinically, it can present as cervical chylous fistula, chylothorax or chylopericardium. Without treatment, the mortality is up to 50% and thus, early aggressive therapy is indicated. Traditional conservative management includes low-fat diet, parenteral nutrition, careful monitoring of fluid and electrolytes, and drainage of the neck wound or chylothorax. Patients with failed conservative management require definitive treatment in the form of ligation of the thoracic duct, which has traditionally been done by thoracotomy. The advent of Video-Assisted-Thoracoscopic-Surgery (VATS) over the last decade has changed the approach towards the management of numerous chest diseases. Thoracoscopic ligation of the thoracic duct has also been reported. We report herein a case of postoperative cervical chylous fistula managed successfully by VATS thoracic duct ligation and present a systematic analysis of the English literature to highlight the current trends in the management of thoracic duct injury.

Adult↗
PubMed2001

[A case of mediastinal thoracic duct cyst].

This is a rare case of thoracic duct cyst in 34-year-old woman. She complained of a left supraclavicular mass and admitted our hospital. A clinical examinations were all within normal limit. The chest X-ray and the magnetic resonance imaging examinations revealed a round tumor 65 x 40 mm in diameter with clear margin located at the left upper mediastinum. The slightly dilated thoracic duct was connected to the tumor. The left supraclavicular vein was compressed by the tumor. The cystectomy was performed under diagnosis of thoracic duct cyst by Trap door method on September, 17, 1999. Macroscopically, thin-capsulated elastic soft tumor contained chyle, and it was connected to the thoracic duct and the left jugular vein. The histological diagnosis was thoracic duct cyst. The postoperative course was uneventful, and the patient was discharged 9 days after operation. The patient remains disease-free at 8 months after the operation.

Adult↗
PubMed1990

Pressure within the thoracic duct modulates lymph composition.

The amount of lymph received by the thoracic duct depends on each contributing organ's ability to produce interstitial fluid and generate a pressure differential moving lymph into the central lymphatic circulation. It has been reported that varying the pressure within the thoracic duct could alter each organ's contribution to thoracic duct flow. The thoracic duct above the diaphragm was cannulated to obtain lymph from the liver, gut, and lower body. Pressure within the thoracic duct was elevated serially by increasing the lymphatic cannula outflow height. This caused lymph protein concentration to increase while chyle concentration (measured by absorbance) decreased. The data demonstrate that as thoracic duct pressure increases, the percentage contribution of gut lymph flow (as represented by chyle concentration) decreases while the contribution of lymph originating within the liver (as indicated by higher protein concentration) increases. We conclude that pressure variation within the central lymphatic system affects the amount of lymph or edema fluid leaving any given organ.

Animals↗
PubMedDate not supplied

[A microsurgical approach to drainage of the thoracic duct in the rat].

Study of thoracic lymph flow is still of interest in gastrointestinal absorption and lymph distribution of different drugs or in immunological studies. A microsurgical experimental model for cannulation of the thoracic duct in rats is described. The principle of the method is the end fistula described by Bollman, allowing the sampling of the total thoracic duct lymph output. A simple method of collecting lymph under free moving conditions was used. The lymph cannulations were one with 0.9 mm outer diameter silicone tubing in 24 Sprague-Dawley rats with an average preoperative weight of 300 +/- 30 g. The daily lymph output measured for up to 10 days in the awake and unrestrained rats varied between 24.4 ml and 97.7 ml/day (average 45.6 ml/ day). The hourly lymph output varied between 0.55 ml and 5.8 ml (average 1.9 ml/h). Patency of the lymph fistulas was 87.5% at five days and 64.3% at the end of the experiment. The rats with failed fistulas presented various degrees of thickening of the lymphatic vessel wall. The average weight loss at the time of euthanasia was 72 g (24%). An accurate technique under the operation microscope and the use of silicone tubing may offer a reliable method in experiments requiring the sampling of the whole thoracic duct lymph output for limited periods of time.

Anesthesia, Inhalation↗