Method: A 12 year old child presented to the oncology service with a recalcitrant massive left pleural effusion, over 20 lb. weight loss, and lytic bone lesions. She was nutritionally depleted and lymphopenic. Analysis of her pleural effusion confirmed a chylous thorax and she failed conservative therapy including hyperalimentation, strict NPO status, and tube thorocostomy. Lymphangiogram demonstrated precise anatomic location of the thoracic duct leak consistent with her chylous output. She underwent a thoracic duct repair with a microvascular lymphaticovenous anastomosis excising a surrounding lymphangioma. Techniques to augment lymphatic flow were used pre- and intra-operatively to demonstrate the leak and to prevent postoperative closure. Microvascular reconstruction utilized the venous valve present in the transcervical vein to separate the lymphatic from the venous system, avoiding thrombosis.

Results: The patient, who had required one month’s intensive hospitalization to evaluate and conservatively manage her chylous thorax, was discharged 9 days postoperatively from her thoracic duct repair. A follow up scintigraphy was done in 6 months to confirm patency and a lymphangiogram was done at 13 months to demonstrate an open and functional anastomosis. She has recovered from her significant weight loss and remained clinically asymptomatic over 4 years.

Conclusions: This is the first reported use of microsurgical lymphatico venous anastimosis of the thoracic duct with proven long term patency. Microsurgical lymphaticovenous repair of the thoracic duct reversed a serious clinical syndrome in this child who presented with the sequalae of a chylous thorax including lymphocyte and nutritional depletion. This reconstruction required the precise anatomic imaging afforded by lymphangiography and specific techniques to ensure its patency.