Lymphovenous anastomosis for recurrent swelling syndrome and chylous effusion due to cervical thoracic duct cyst

Abstract

Thoracic duct (TD) cyst is an uncommon abnormality that can be manifested as a cervical swelling. Pathogenesis includes congenital or degenerative weakness of the wall of the TD and obstruction of the lymphoid flow. Diagnosis is crucial to eliminate malignant disease or vein thrombosis and can be established by imaging and needle aspiration. We report a case of recurrent cervical swelling with spontaneous chylothorax and chyloperitoneum. A TD cyst with a terminal obstruction of the TD was diagnosed on lymphangiography. Treatment by microsurgical lymphovenous anastomosis was successful, and the patient was free of symptom 3 years later.

Variations in the Management of Cervical Thoracic Duct Cyst

“…Reported investigations include angiocardiography, FNA for cytology and biochemical testing, ultrasonography, open biopsy, colour-coded Doppler, lymphoangiography (also known as lymphography), cystography (direct puncture of contrast media to cyst), lymphoscintigraphy, CT, MRI, and PET scan. Lymphangiography is considered as the ‘gold standard’ imaging tool by many authors as this delineates the mediastinal and cervical segments of the thoracic duct up to the inlet to the junction of the left subclavian vein and internal jugular vein [4-7]. It can also be combined with aspiration techniques.…”

“…The cause of CTDC is unclear. Several aetiologies have been proposed including congenital weakness [11-13], distal obstruction of the duct [14, 15], degeneration of cervical thoracic duct wall from inflammation or atherosclerotic changes [4, 7, 16], and neck trauma which could be iatrogenic [17] or secondary to blunt injury like whiplash [18-20]. Our literature review reported that the possible pathogenesis are distal obstruction (16/47; 34%), wall degeneration (7/47; 15%), trauma (5/47; 11%), congenital wall weakness (4/47; 9%), and a third had unknown cause or not elaborated in the full report (16/47; 34%).…”

“…The case had an impressive 25-year follow-up including repeat CT and MRI, which showed complete resolution of the cyst. Keeping a strict low-fat diet can cause improvement of symptoms [7]. Franceschi et al [23] reported effective resolution of distal obstruction that was causing the cystic dilatation by tough compression using the echo-colour Doppler probe.…”

“…To help identify the cyst and its branches intra-operatively, some authors advocated high fat intake immediately before the operation. Mattila et al [26] give their patient 100 mL of thick cream by mouth 2.5 h before surgery, while Veziant et al [7]allow a high-fat meal 4 h pre-operatively. Most cases reported no difficulties in identification of the cyst and its branches, which were ligated and excised.…”

“…Most cases reported no difficulties in identification of the cyst and its branches, which were ligated and excised. Aside from excision, other surgical approaches include side-to-side anastomosis between the thoracic duct and the internal jugular vein [23] or cyst-venous anastomosis [7, 8]. Other potential complications of surgery are injury to local structures such as nerve damage (accessory, phrenic, recurrent laryngeal nerves), pneumothorax, injury to major vessels, arm swelling apart from scarring, pain, and infection although none of these were reported in the current literature reviewed.…”