Page 11 - Read Online

Page 6 of 8 Grünherz et al. Plast Aesthet Res 2023;10:20 https://dx.doi.org/10.20517/2347-9264.2023.24

Thus, we performed a microsurgical anastomosis of the thoracic duct to a nearby vein to restore lymphatic
drainage. In one patient, the lympho-venous anastomosis was performed for the first time subdiaphragmal
to a phrenic vein resulting in complete resolution of the therapy-refractory chylothorax. In this patient,
abdominal and thoracic drains could be removed by days eight and fourteen, given an output below 10
ml/ 24 h. At a two-year follow-up, this patient is still asymptomatic.

In the other patient, the thoracic duct was anastomosed to the left external jugular vein. Although
anastomosis was patent and output from the abdominal drain decreased significantly, only partial remission
[35]
could be achieved . In this patient, the thoracic duct at the neck and within the thorax was severely dilated,
indicating a lack of tonus and peristalsis. Whether this was due to the long-time chronic pressure at the
occluded left venous angle or due to a congenital hypomotility of the thoracic duct could not clearly be
distinguished. This, however, underscores the importance of early reconstructive treatment and the
relevance of a toned thoracic duct in order to transport the chyle against gravity.

In our experience, venous pressure in the selected vein for lymphatic anastomosis should be low to facilitate
lymphatic flow from the thoracic duct into the venous system. Alternatively, if higher venous pressure
exists, a vein graft with valves can be interposed because, under physiologic conditions, a valve is present at
the left lympho-venous angle preventing the reflux of venous blood into the thoracic duct. Furthermore,
when performing thoracic duct-venous anastomoses in the abdomen, veins connected to the caval system
should be chosen, as there is no experience to date on the effects of additional chyle flow into the portal
system.

FUTURE PERSPECTIVES
We have recently demonstrated the feasibility and safety of the Symani Surgical System (Medical
Microinstruments (MMI), Wilmington, USA) for lymphatic microsurgical procedures [36,37] . The Symani
Surgical System, which has been solely developed for robotic microsurgery, provides several valuable
features such as motion scaling and tremor reduction [Video 1] Furthermore, the robotic arms of the
system allow easier access to deep structures through smaller incisions. This opens the possibility of using
the system for central lymphatic surgery of the thoracic duct, which will be the subject of further
investigation.

Central lymphatic surgery may also become relevant in the treatment of patients after the Fontan
procedure. This procedure is performed in children with a single functional ventricle. Lymphatic
dysfunction in the Fontan circulation is among the postoperative complications and leads to plastic
bronchitis and protein-losing enteropathy. The situation may be complex due to often elevated venous
pressures in the Fontan circulation. However, in selected cases, lymphatic flow may have been mechanically
interrupted by repetitive heart surgery and thoracic duct reconstruction may be a promising strategy to
reestablish lymphatic flow and reduce symptoms. Current treatment strategies include lymphatic
[38]
embolization and thoracic duct decompression . A new approach could be the creation of an anastomosis
between the thoracic duct and a nearby vein to redirect lymphatic drainage. However, against the
background of the underlying disease with significantly impaired cardiac function and increased
perioperative risks, the indication must be made with utmost caution and microsurgical treatment should
only be offered in specialized centers.

CONCLUSION
There is an increasing number of reports with successful outcomes after thoracic duct-vein anastomoses in
adults as well as in children with acquired or congenital central lymphatic lesions. Treatment success may