The Journal of Cardiothoracic Trauma

REVIEW ARTICLE
Year
: 2021  |  Volume : 6  |  Issue : 1  |  Page : 15--21

Thoracic duct injury: An up to date


JosÚ Luis Ruiz Pier1, Moheb A Rashid2,  
1 Cardiothoracic Surgeon at Hospital de Traumatología “Victorio de la Fuente Narváez” Instituto Mexicano del Seguro Social, Mexico City, Mexico
2 Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden

Correspondence Address:
JosÚ Luis Ruiz Pier
Cardiothoracic Surgeon at Hospital de Traumatología “Victorio de la Fuente Narváez” Instituto Mexicano del Seguro Social, Mexico City
Mexico

Abstract

Trauma represents a significant portion of the world's morbidity and mortality. Chest trauma accounts for approximately 25% of mortality in trauma patients, and this rate is much higher in patients with polytraumatic injuries. The thoracic cavity contains three major anatomical systems: the airway, lungs, and the cardiovascular system including the thoracic duct. Blunt or penetrating trauma can cause significant disruption to each of these systems that can quickly prove to be life threatening unless rapidly identified and treated. In the present article, the authors present a review of the thoracic duct injury evaluation and treatment.



How to cite this article:
Ruiz Pier JL, Rashid MA. Thoracic duct injury: An up to date.J Cardiothorac Trauma 2021;6:15-21


How to cite this URL:
Ruiz Pier JL, Rashid MA. Thoracic duct injury: An up to date. J Cardiothorac Trauma [serial online] 2021 [cited 2022 Jan 28 ];6:15-21
Available from: https://www.jctt.org/text.asp?2021/6/1/15/333278


Full Text



 Introduction



Trauma represents a significant portion of the world's morbidity and mortality. According to the World Health Organization, over nine people die per minute due to some type of trauma, with a health expense equivalent to 12% to all diseases.[1] It has been estimated that of the 11 million deaths per year in the developed world, 0.8 million are the result of trauma. In recent research, the male sex predominated in chest trauma. Blunt trauma, as a result of road accidents, have affected more frequently the right side of the chest, while the left side was more commonly affected in penetrating injuries.[2]

The presence of severe lung contusion, a higher injury severity score, and abbreviated injury scale thoracic score, and advanced age are independent risk factors that are directly related to a higher mortality rate. The majority of the patients with a thoracic injury can be managed in emergency room with chest tube insertion, optimal pain control, and chest physiotherapy result in good outcomes in the majority of patients.[3],[4]

Chest tube is important for the drainage and evaluation of the amount and characteristics of the pleural collections from blunt or penetrating trauma, and it is considered the first-line approach.[5] Surgical exploration after thoracic trauma is rare, accounting for about 15% being penetrating trauma more likely to require surgical exploration than blunt trauma.[6]

Historically, lymphatic vessels have been considered on second place regards the rest of the circulatory system, because the size of the ducts and the colorless fluid content. The thoracic duct was first described in 1651 by Jean Pecquet, and this finding contradicted the Galen´s theory which stands that chyle was conducted by intestinal vessels directly to the liver, nevertheless the chylothorax was first described by Bartolet in 1633, and postulated that it was caused by rupture or obstruction of the thoracic duct or its branches, resulting in chyle leakage into the pleural space.[7]

 Anatomy and Embryology



The formation of the thoracic duct begins between the 7th and 8th weeks of gestation, when the two vessels connect the lymphatic jugular sacs and the cisterna chyli. Initially, there were two thoracic ducts with multiple anastomoses between them, and the definitive duct is formed by the inferior portion of the right duct, transversal anastomoses, and the superior portion of the left duct.[8],[9]

The thoracic duct is classically divided into three portions: abdominal, thoracic, and cervical [Figure 1]. Anatomic variations have been described from necropsy studies, the most common in the terminal site, 46% ended in the internal jugular vein, 32% in the jugulosubclavian junction, and 18% in the left subclavian vein.[10]{Figure 1}

 Physiology



The lymphatic system primary function is to transport chyle from the gastrointestinal tract into the systemic venous system, working as a diffuse network of vasculature that, transports, and reabsorbs a wide variety of molecules and cells. Contrary to the circulatory system that is propelled by the heart; the lymphatics use osmotic and oncotic forces, smooth muscle within vessel walls, and muscular contractions; and a combination of intrathoracic and intra-abdominal pressures and arterial pulsations helps in maintaining lymph flow in the thoracic duct. Morphological studies have confirmed that human lymphatic vessels are innervated, but recently, it has been demonstrated functionally that the thoracic duct innervation is predominantly adrenergic, and the functional contribution appears to be low. It carries almost 4 l of chyle daily, most of which originates in the digestive tract. The flow rate can be up to 100 ml per kilogram of body weight per day, depending on the diet consumed.[11],[12]

 Etiology of Thoracic Duct Injuries



Thoracic duct leaks are most often due to traumatic injury,[13],[14],[15],[16] and iatrogenic injury.[17] The first documented case of traumatic thoracic duct injury was described by Quincke in 1875.[18] Traumatic transection of the thoracic duct due to chest trauma is unusual and rare.[19],[20] Approximately 3% of the patients with blunt thoracic trauma and 1.3% of penetrating thoracic trauma demonstrate thoracic duct leaks.[21] In addition, it is often identified late.[22],[23] The onset of symptoms depends on the etiology, and there are reported unusual causes, as simple or heavy exercise, blunt torso trauma, falling from heights, whiplash mechanism and other forms of neck hyperextension[24],[25],[26],[27],[28],[É29] with traumatic or surgical causes presenting earlier compared to the other etiologies, at this point transections due to stab or gunshot injuries are included[30],[31],[É32] [Figure 2].{Figure 2}

 Clinical Presentation



Typically, patients present with dyspnea due to pleural effusions.[33] Chronic leaking of chyle also results in malnourishment and susceptibility to infections, which is seen in nontraumatic causes as in malignancy or tuberculosis.[34],[35] However, in surgical and traumatic causes, the onset of symptoms may be immediate if the volume is more than 500 ml/day.[36],[37],[38]

Examination may reveal decreased breath sounds and dullness to percussion in areas of lymph collections. The symptoms are usually observed after 3 to 7 days following the injury, and then, the patient may go into collapse, characterized by dyspnea and hypotension, so that no radial pulse can be felt.[39],[40] Drainage of the fluid results in a most dramatic relief of all the symptoms, and within a few minutes, the patient is apparently well again. As the fluid reaccumulates, this chain of symptoms may be repeated again and again.[41] Depending on the level of injury, the chylothorax then may develop on one side, or bilaterally.[42],[43],[44],[45] Despite management with drainage and strict dietary changes, the need for surgical intervention may become necessary. A chylothorax should be considered in the differential diagnosis of trauma patients who sustain blunt chest trauma, particularly when these patients have thoracic injuries with pleural effusions. Patients who are symptomatic from chyle loss or have a high output of chyle will require surgical intervention.[46],[47],[48]

 Investigations



After a complete history and clinical examination, the workup of the suspected thoracic duct leakage includes blood examination with complete blood cell count, serum glucose, total protein, triglycerides, albumin, and lactate dehydrogenase. Initially, a chest radiograph may show pleural effusion.[49]

Usually, it is unilateral in up to 78% of patients, and it involves the right side more commonly. As mentioned above, the varied course of the thoracic duct and its site of leak dictates the side of pleural effusion, injuries to the duct below the 5th thoracic vertebrae result in pleural effusion on the right side, and damage above this level occurs in a left-sided pleural effusion. Disruption of multiple tributaries to the thoracic duct can produce pleural effusion bilaterally. High suspicion should arise when a pleural effusion is recurrent or persistent, more so when it is milky, turbid, or serosanguinous.[50]

The analysis of the pleural fluid will show white cell count with lymphocyte predominance and a nucleated cell count >70%. Triglyceride levels >110 mg/dL and cholesterol <200 mg/dL are typically found in patients suspected to have chylothorax. A triglyceride level >240 mg/dL has a sensitivity and specificity of >95%. The definitive diagnostic test is the detection of chylomicrons in the fluid by lipoprotein electrophoresis, though not performed routinely due to its high expense and availability.[51]

After confirming the presence of chylothorax, patients require additional evaluation to find out the etiology for the leak, and that includes computed tomography (CT) of the chest and abdomen. Although at times, CT may not provide the site of the leak and also in the presence of thoracic duct anomalies, CT may not yield much information.[52],[53]

Lymphangiography entails the injection of methylene blue in the subcutis of digits and is carried by the pedal lymphatics into the central system. Furthermore, Lipiodol contrast can be injected into the lymphatic vessel, and the probable site of the leak and anatomical variations can be visualized using fluoroscopy.[54],[55]

Lymphoscintigraphy is the injection of a technetium 99-labeled agent into the dorsum of the foot bilaterally. Later, imaging is done with single-photon emission computerized tomography which gives a good visualization of the thoracic duct.[56]

Recent studies suggest that near-infra-red fluorescence is nonionizing imaging and an easy-to-use method to detect thoracic duct leaks in open surgery or thoracoscopic interventions. Yet, no application to percutaneous sclerotherapy has been described, and hence it can also be a useful tool for percutaneous sclerotherapy.[57]

 Treatment



The treatment of thoracic duct injuries and chylothorax is focused on decompression of the thorax, prevention of malnourishment, and close chyle leaks. This objective can be achieved by different means depending on the etiology, site of the transection, amount of chyle loss, and patient conditions. For the closure of the leakage, there are proposed nonsurgical procedures as well as thoracotomy with direct ligation of the thoracic duct or by thoracoscopy.

Nonsurgical treatment

There are no randomized, controlled studies to direct the management of chylothorax because of its infrequent occurrences and diverse presentations. The initial approach includes chest tube drainage that is considered to be effective and provides a mean of accurately monitoring the rate of chyle leakage.[58]

Severe nutritional depletion and immunodeficiency as a result of the loss of large amounts of chyle. The metabolic management includes monitoring the patient's weight, serum albumin, total protein, absolute lymphocyte count, and electrolytes. Along with replacing the daily losses, dietary modification can address nutritional needs. Administration of medium-chain triglycerides as a source of fat is an invaluable adjunct in the conservative management of chylous pleural effusions, with the objective of avoid malnutrition, minimize the thoracic duct flow to promote healing of the leak. If drainage remains unchanged, then oral intake should be discontinued, and total parenteral nutrition should begin. Some authors believe that the optimal approach includes a regimen of no oral intake, total parenteral nutrition, and chest tube drainage.[59]

Adjunct therapy with octreotide, a somatostatin analog that has an inhibitory effect on lymphatic fluid excretion, however, may be less effective in patients with a chest tube output of >1 L/d.[60]

Conservative treatment of lymph leakage in the absence of serious clinical symptoms, with patient monitoring and diet changes, has been shown more preferable than the invasive approach, although current data are insufficient to definitely confirm it. Failures occur in roughly 50% of patients and are more likely when chest tube output is >500 mL/d. In these patients, a more aggressive approach is necessary.[61]

The first report describing the percutaneous treatment of chyle leak with catheterization of the cisterna chyli in humans was published by Cope in 1998.[62] In the following years, his experience was replicated by other authors.[63]

The percutaneous embolization of chylothorax is a minimally invasive procedure that can be performed using local anesthesia with the patient under conscious sedation associated with no mortality and minimal morbidity. The technique starts with a radiologic demonstration of the cisterna chyli via pedal lymphography, followed by percutaneous, transperitoneal access to the cisterna chyli using a modified Seldinger technique. Once a catheter has been correctly inserted, the thoracic duct is opacified with nonionic contrast medium. After identification of the leak, embolization of the duct is performed with microcoils, glues,[64] or both.[65]

The whole procedure is usually accomplished in about 3 h, but challenging cases can require twice this time. An advantage over surgery of the percutaneous technique is that it can identify all branches of the thoracic duct and the specific site of leakage while allowing embolization of one or more leak sites.[66],[67] It has been used to resolve chyle leakages after surgical procedures,[68] and even an unsuccessful thoracic duct ligature surgery avoiding reinterventions with success.[69]

There has been reported an approach using endoscopic ultrasound and fine-needle injection directly into the thoracic duct 1.5 ml of sodium morrhuate, using color flow Doppler to identify surrounding structures and delineate its relation to the azygous vein.[70] The use of intrapleural streptokinase, 250,000 units twice daily for 3 days, in one patient result in a decrease in the amount of leakage, but no other reports in this regard have been found.[71]

Surgical treatment

Approximately 50% of patients with traumatic chylothorax fail to respond to nonsurgical management and usually necessitate surgical intervention. This is achieved by thoracic duct ligation using right thoracotomy. This operation entails single-lung ventilation with access to the thoracic duct by a seventh interspace right lateral thoracotomy. The thoracic duct is isolated low in the chest within soft tissue between the esophagus, aorta, and azygous vein overlying the vertebrae [Figure 3]. Exposure can be aided by placing a temporary nasogastric tube in the esophagus, and downward retraction of the diaphragm. This soft tissue is mass ligated at three adjacent positions with nonabsorbable suture [Figure 4]. Patients are kept nothing per mouth on total parenteral nutrition for 5 days postoperatively before advancing the diet to confirm resolution of the chyle leak.[72] It has been reported during tumor resection; parts of the thoracic duct were removed which resulted in a large lymph leak. This was addressed by creating a lymphovenous anastomosis to a branch of the subclavian vein, with no longer follow-up to recommend it as a regular practice.[73],[74],[75]{Figure 3}{Figure 4}

Thoracotomy has long been the conventional surgical approach in dealing with chylothorax due to thoracic duct injury which has been refractory to conservative treatment.[22] The development of video-assisted thoracoscopic surgery (VATS) provides an alternative means of dealing with thoracic duct injuries, thereby reducing the morbidity from thoracotomy and prolonged chylous leak.[76] Inderbitzi first reported the successful thoracoscopic management of a postoperative chylothorax by fibrin glue application.[77] The literature supports the use of VATS for specific indications including thoracic duct injury. Patients with traumatic chylothorax should be given the opportunity of conservative management given the rate of response to this approach. If treatment fails, VATS can provide superior visualization of the duct over the traditional open surgical approach due to the magnification of 10-folds, thus the thoracic duct can be clearly seen, and the angled camera provides a view under the vertebral body.[78],[79]

Conservative treatment is expensive and fails in the majority of the high-output chylous fistulae. On the other hand, VATS is uniformly effective and is less expensive with low morbidity. Surprisingly, however, conservative treatment continues to be recommended by most authors.[80]

Acknowledgment

We acknowledge the assistance of Hania Ruiz Bugarin for her help with drawing the diagram of [Figure 1].

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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