Identification of Laceration of the Thoracic Duct by Lymphangiography. Preoperative Radiography of the Traumatized Thoracic Duct

Chylothorax or chylous ascites is an occasional result of abdominal or thoracic trauma or of surgical procedures. There are two earlier reports (3, 7) of injury to the thoracic duct following aortography, and this paper records an additional case. Although the injury may be deduced from the chylous effusion, the difficulty lies in identification of the site of perforation in order to facilitate surgical repair. Lymphangiography provides a technic for positive and precise localization of the lesion. Identification and demonstration of lymphatic channels and lymph nodes by the injection of radiopaque material directly into the lymphatic vessels have proved valuable aids to the surgeon, internist, and therapist in several clinical problems (10). Lymphangiography is useful in evaluating adequacy of lymph node dissection, distinguishing lymph and venous edema, defining radiotherapy portals, and differentiating the lymphomas (1). This report introduces the application of this technic to localization of traumatic perforation of the thoracic duct, to facilitate surgical repair. The para-aortic channels empty into the cisterna chyli, which is located along the anterior aspect of L1. The cisterna chyli continues upward as the thoracic duct, in close relation to the anterior surface of the thoracic vertebral bodies and between the aorta and the azygos vein. The duct swings to the left at T5, passes behind the aorta, and continues along the dorsal vertebrae. It then angles forward fairly acutely at the level of T2 and terminates by entering the venous system at the junction of the left subclavian and internal jugular veins. There are many variations from this pattern, and in about 10 per cent of cases emptying is on the right. The lymphatic vessels, cisterna chyli, and the thoracic duct are frequently seen on x-ray films made immediately upon completion of the injection of iodized oil into peripheral lymph channels (5). In the case to be presented here the thoracic duct was inadvertently injured during aortography. Puncture of the duct is a rare complication of aortography, only 4 cases having been reported recently (3, 7). To our knowledge, the preoperative radiographic demonstration of the point of leakage (Fig. 1) and the fistulous tracts (Fig. 2) has not been recorded previously. Case Report A 34-year-old woman was admitted to the hospital Dec. 12, 1962, for investigation of hypertension. Renal arteriography was successfully performed by the translumbar method. The patient was discharged Dec. 14, and readmitted Dec. 31, with a four-day history of non-productive cough, fever of 101°, and slight dyspnea. Radiographic examination revealed a large pleural effusion on the right, and 600 c.c. of milky fluid was removed by thoracentesis. The diagnosis was chylothorax following perforation of the thoracic duct. Spontaneous sealing of the perforation was anticipated, but in the ensuing twenty-five days almost 12 liters of fluid were removed.