2. Thoracic duct
- Is the largest lymphatic trunk which
drains chyle(product of fat digestion) &
most lymph of body.
- Extent- Upper abdomen at lower
border of T12 to lower part of neck,
crossing post & sup mediastinum
- 45cms long & 0.5cms wide
- Appears Beaded due to presence of
many valves in its lumen
2
3. Drains lymph from whole of body except
• Rt side of head & neck
• Rt upper limb
• Rt lung & thoracic wall
• Rt side of heart and rt surface of liver
AREA OF DRAINAGE
3
4.
5. COURSE:
* BEGINS IN ABDOMEN AT LOWER BORDER
OF T12 AS A CONTINUATION OF CISTERNA
CHYLI
* ENTERS POST MEDIASTINUM THROUGH
AORTIC OPENING OF DIAPHRAGM(T12)
* AT T5 SHIFTS TO LEFT & RUNS IN
SUPERIOR MEDIASTINUM
* AT C7 (ROOT OF NECK) ARCHES
LATERALLY, THEN DOWNWARDS
* ENDS AT ANGLE FORMED BY UNION OF
LEFT INT JUGULAR VEIN & LT SUBCLAVIAN
VEIN, (REGURGE OF BLOOD PREVENTED BY A
PAIR OF VALVES)
6. COMPOSITION OF CHYLE
Lipids - 60% to 70% of ingested fat absorbed by
intestinal lymphatics.
Proteins
Electrolytes
Cellular Elements
Miscellaneous Elements - Fat soluble vitamins,
antibodies, urea nitrogen, and enzymes
7. CHYLOTHORAX
A chylothorax (or chyle leak) is a type of pleural
effusion. It results from lymph formed in the
digestive system called chyle accumulating in the
pleural cavity due to either disruption or obstruction
of the thoracic duct.
In a normal adult, the thoracic duct transports up to
4 L of chyle per day, allowing a rapid and large
accumulation of fluid in the chest
The prevalence after various cardiothoracic
surgeries is 0.2-1%.
8. CHYLOMA
a collection of chyle below the pleura develops
when the thoracic duct first leaks
severe chest pain, dyspnoea and tachycardia
10. subclavian vein catheterisation and duct blockage
due to central venous catheterisation related
venous thrombosis
Yellow nail syndrome-bronchiectasis, sinusitis ,
hypoplastic lymphatics, yellow nails (due to slow
growth), lymphoedema, particularly of the lower
limbs and pleural effusions
11. SIGNS AND SYMPTOMS
Hypovolaemia
Respiratory difficulty
malnutrition due to the loss of protein, fats and
vitamins - weight loss and muscle wasting
hyponatraemia and hypocalcaemia
Immunosuppression
Empyema is a rare due to bacteriostatic nature of
lecithin and fatty acids
Decreased breath sounds
Shifting dullness
13. The effusion may be unilateral, either right (50%) or
left sided (33.3%), or bilateral (16.66%) and is
dependent on the location of the leak. Damage to
the duct above the fifth thoracic vertebra results in a
left sided effusion whereas damage to the duct
below this level leads to a right sided effusion
14. INVESTIGATION
confirmation of the diagnosis by fluid analysis
identification of the leakage point
Investigation should continue until the aetiology
15. fluid will not always be milky or white
and may for example be blood stained
after trauma or even serious in
appearance if the patient is fasting
Collecting the fluid into an EDTA tube
allows for cell counts on the sample.
16. thoracentesis and laboratory analysis of the pleural
fluid
centrifugation of pleural fluid
adding 1-2 ml of ethylether
fluid stained with Sudan III
18. CT abdomen and thorax
Lymphangiograph
High fat content feed mixed
with methylene blue
19. BIOCHEMICAL DIAGNOSIS OF CHYLOTHORAX
pleural fluid triglyceride of >110 mg/dl had a 1%
chance of being non-chylous and that a triglyceride
of <50 mg/dl had a 5% chance of being chylous.
As a result, pleural fluid triglyceride levels>1.24
mmol/l (110 mg/dl) with a cholesterol<5.18 mmol/l
(200 mg/dl) is diagnostic of chylothorax
22. Treatment is initially conservative:
1. Tube drainage.
2. Medium-chain fatty acid diet.
3. Fluid and electrolyte support.
4. NPO and TPN
5. Somatostatin
Failure of conservative treatment requires
surgical solution
23. OPERATIVE TECHNIQUES
Direct ligation of thoracic duct
Supradiaphragmatic mass ligation of the thoracic
duct
Video Assisted Thoracic Surgery (VATS)
‡‡Pleurodesis
Fibrin glue
24. DIAGNOSTIC CONSIDERATIONS
Timing of surgical management is controversial and
depends on the etiology of the chylothorax and the
patient's overall condition.
Patients with postesophagectomy chylothorax have
a 50-82% mortality rate if treated conservatively.
A malignant etiology of the chylothorax must be
ruled out, as greater than 50% of cases are due to
malignancy, of which lymphoma accounts for
approximately 75% of cases, followed by lung
carcinoma.
25. ETIOLOGICAL TREATMENT
sarcoidosis with steroids
cardiac failure with diuretics
Malignancy with radiotherapy or chemotherapy if no
improvement then pleurodesis
26. If the leak is in the
region of the neck or
upper thorax, the
thoracic duct is ligated
in the area known as
Poirier’s triangle
between the arch of
the aorta, internal
carotid and vertebral
column
27. Ligation of the thoracic duct is
successful in 90% of patients
when performed just above
the right hemi-diaphragm
30. too unfit for major surgery or have malignancy, a
pleuroperitoneal shunt may be useful .
complications such as infection, adhesions, and
clogging of the implants
1% Evans blue dye can either be injected into the
web space of the toes for uptake into the lymphatic
space to increase visualization.