Thoracic duct-to-vein anastomosis for the management of thoracic duct outflow obstruction in newborns and infants: a CASE series

• Published in: Journal of pediatric surgery 2020-02, Vol.55 (2), p.234-239
• Main Authors: Reisen, Breanne, Kovach, Stephen J., Levin, L. Scott, Pinto, Erin, Nadolski, Gregory J., Itkin, Maxim, Dori, Yoav, Laje, Pablo
• Format: Article
• Language: English
• Subjects: Lymphatic system; Lymphovenous anastomosis; Microsurgery; Thoracic duct obstruction
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/j.jpedsurg.2019.10.029

Thoracic duct (TD) outflow obstruction causes high morbidity and mortality in newborns. It can be congenital/idiopathic or acquired (secondary to central venous thrombosis or injury during cardiothoracic surgery). Re-routing the TD to the venous system by microsurgical techniques to restore lymphatic flow is a potential surgical solution. We present a series of newborns and infants who underwent thoracic duct-to-vein anastomosis (TDVA) to restore TD outflow. A retrospective review of all TDVA September 2015–March 2019 was performed. All patients underwent extensive pre-operative imaging evaluation by dynamic MRI and fluoroscopic lymphangiography. The TDVAs were done under high-power microscopy. Eight patients underwent TDVA. Age at surgery was 1 to 9 months. Four patients had a history of cardiac surgery (one with complete thrombosis of the central venous system), one patient had a history of ECMO and thrombosis of the SVC, and three patients had a history of fetal hydrothorax and non-immune hydrops. Six patients had a successful TDVA with restoration of the lymphatic flow through the TD and clinical improvement. Two patients had a technically adequate TDVA but without improvement of the flow due to persistently high central venous pressure. Five patients remain alive, two patients died from complications of the lymphatic disorder, and one patient died from an unrelated cause. Patients with congenital or acquired TD outlet obstruction for whom no improvement is achieved by non-surgical interventions may benefit from TDVA. A thorough understanding of the anatomy and physiology of each patient is critical for the success of the operation. Level IV.