Microsurgical Thoracic Duct Lymphovenous Bypass in the Adult Population

Abstract

Thoracic duct occlusion can lead to devastating complications, resulting in recalcitrant chylothoraces, ascites, generalized lymphedema, metabolic derangement, and death. Lymphatic extravasation has traditionally been managed conservatively and, in recent years, using minimally invasive techniques, such as thoracic duct ligation and embolization. However, these measures are often limited in application and therapeutic success, resulting in chronically difficult conditions with few modalities available for definitive management. Advances in microsurgery have allowed for surgical treatment and resolution of peripherally-based lymphatic pathology, though microsurgical intervention to address central lymphatic abnormalities is scarcely described. This report is the first series detailing experiences utilizing microsurgical thoracic duct lymphovenous bypass in a refractory adult population with thoracic duct occlusion. Four patients successfully underwent the procedure, with three achieving complete resolution of symptoms. The fourth patient enjoyed partial resolution, though ubiquitous lymphatic deformities have conferred recurrent residual lower-extremity peripheral edema requiring future intervention. Postoperatively, patent anastomoses were confirmed under magnetic resonance lymphangiography. This series demonstrates the feasibility of microsurgical thoracic duct lymphovenous bypass as a promising technique in treating patients suffering from thoracic duct occlusion. This intervention is effective for recalcitrant chylothorax, chylous ascites, and generalized lymphedema, particularly when traditional and interventional radiological techniques are unsuccessful.