Central Lymphatic Obstruction

Abstract Purpose of Review Central lymphatic obstruction (CLO) represents a poorly understood area of medicine and physiology. CLO is characterized by obstruction of the thoracic duct at different anatomic levels within its course with resultant downstream manifestations. This review will focus on treatment of central lymphatic obstruction, including nonsurgical approaches and, when applicable, surgical reconstruction in the form of lymphovenous bypass of the thoracic duct. Recent Findings Thoracic duct occlusion results in an inability of antegrade flow of lymphatic fluid into the central venous circulatory system. Due to this flow obstruction patients have significant complications including lymphedema and organ specific chylous fluid accumulations. While conservative management such as a low-fat diet, medications such as diuretics, and percutaneous drainage of symptomatic ascites or chylous pleural effusions can temporarily alleviate symptoms, they do not result in permanent resolution of symptoms. Lymphovenous bypass involving the thoracic duct and regional veins is under investigation and has effectively alleviated symptoms associated with central lymphatic occlusion in adults and pediatric patients. However, patients are only candidates for a bypass procedure based on specific anatomic patterns of obstruction. These outcomes underscore the importance surgical approaches to thoracic duct occlusion in appropriately selected patients who are otherwise unresponsive to conservative treatment. Summary Untreated thoracic duct occlusion is debilitating and can significantly worsen quality of life. Given the associated organ disfunction and malnutrition, patients have increased morbidity and mortality emphasizing the need for surgical intervention. By leveraging intraoperative lymphangiography and fluoroscopy, an innovative surgical technique was developed to allow thoracic duct visualization and perform direct anastomosis with the thoracic duct to a nearby vein, typically the external jugular. This novel lymphovenous anastomosis redirects lymphatic fluid into the venous system, thereby alleviating symptoms associated with thoracic duct occlusion or stenosis. Since proximal thoracic duct anomalies can present in any one patient due to a variety of causes, lymphovenous anastomosis has been applicable to neonatal, pediatric, and adult patients.