The lymphographic anatomy of chylothorax

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Abstract
A detailed lymphographic study of 3 cases of chylothorax (in thoracic duct laceration, in Hodgkin''s disease and in Noonan''s syndrome, respectively) was correlated with the anatomy of thoracic lymph drainage. Chylothorax can only occur by laceration or obstruction of the thoracic duct. After leakage of chyle into the mediastinum from a lacerated thoracic duct, it can then leak into the pleural cavity either because of damage to the parietal pleura by the initial trauma or because the pleura breaks down under the pressure of the mediastinal effusion. Injury where the duct lies on the right side of the aorta is more likely to produce a right chylothorax; injury where it lies on the left of the esophagus is more likely to produce a left chylothorax. There are many collateral vessels connecting lymphatics to veins and connecting the thoracic duct to the lymphatics of the right hemithorax; it is only if these are defective that thoracic duct obstruction may cause chylothorax. This chylothorax should be purely or predominantly on the left side as the thoracic duct does not drain the right hemithorax; for right chylothorax to occur, there must be obstruction of the right thoracic lymphatics as well as of the thoracic duct. Chyle may reflux from an obstructed thoracic duct by 2 routes, via the left posterior intercostal lymphatics to the parietal pleural lymphatics and via the left bronchomediastinal trunk to lymphatics of the pulmonary parenchyma and visceral pleura. If the bronchomediastinal trunk enters the great veins independently of the thoracic duct, the latter route will not be taken. From visceral or parietal pleural lymphatics, chyle then extravasates into the pleural cavity.