Chapter 111

The thoracic duct or its tributaries can sustain injury as a direct result of thoracic surgery or trauma. Chylothorax is an unusual but serious complication of thoracic surgery, particularly esophagectomy.1 Management of patients with postoperative chylothorax can be difficult. Traditional conservative treatment includes chest tube drainage and low-fat total parenteral nutrition to decrease the physiologic production of chyle. Although this therapy is sometimes successful in patients with low-output leaks, it is less effective for large leaks (i.e., >500 mL/d). In high-output patients, repeat thoracotomy and direct thoracic duct ligation typically are performed to stop the leak (see Chap. 113). In this patient population, however, surgical thoracic duct ligation can be difficult owing to nutritional and immunologic depletion. As a result, some have called for earlier diagnosis and intervention to avoid metabolic deterioration and death.2–5

Less invasive techniques have been suggested to lessen the morbidity associated with repeat thoracotomy. Some have advocated video-assisted thoracoscopic techniques to identify the thoracic duct for ligation.6,7 More recently, percutaneous thoracic duct embolization has been introduced as a novel and noninvasive technique for controlling high-output chylothorax8 (Fig. 111-1). In this chapter we review the indications, preprocedural imaging, and technique of percutaneous thoracic duct embolization.

###### Figure 111-1.

An anteroposterior radiograph of the upper abdomen in a patient who has undergone thoracic duct embolization shows coils and radiopaque glue in the thoracic duct.

The method of thoracic duct embolization for the control of chylothorax requires a comprehensive understanding of the anatomic structures adjacent and anterior to the cisterna chyli. The approach requires puncture and cannulation of the lymphatic system with a 21-gauge needle. The course of the needle is through the anterior abdominal wall and peritoneum. Puncture of visceral structures and solid organs is unavoidable. The location of the cisterna is extremely variable and is the reason why we obtain preoperative MRIs. Careful attention must be paid to the renal arteries and aorta, which can be in very close proximity to the target. The preoperative MRI is the key to avoiding these structures.

Patients who have a large-output chylothorax that has not responded to conservative care are appropriate candidates for thoracic duct embolization. It is easier to perform embolization on patients before attempts at operative repair, which distorts the lymphatic anatomy and makes cannulation more difficult.

A preoperative MRI is critical to the preoperative assessment of patients undergoing thoracic duct embolization. Because of the close proximity of the cisterna chyli to the right renal artery and aorta, preoperative imaging is critical to determining a safe approach. Thin-slice coronal T2 images have proved the most useful series in making this determination (Fig. 111-2A). It is also important for the patient to have a normal coagulation profile because the needle will traverse many abdominal structures on ...

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