Cannulation of the thoracic duct and umbilical vein in patients with portal hypertension

Indications, techniques, and clinical outcomes of thoracic duct interventions in patients: a forgotten literature?

BACKGROUND

The evolution of the "gut-lymph concept" has promoted thoracic duct (TD) lymph drainage as a possible treatment to reduce systemic inflammation and end-organ dysfunction in acute illness. The aim was to review the published experience of thoracic duct interventions (TDIs) aimed at improving clinical outcomes.

METHODS

A search of three databases (MEDLINE, EMBASE, and EMBASE CLASSIC) over the last 60 y. The indications for intervention, the technique, and clinical outcomes were reviewed.

RESULTS

There were a wide range of indications for TDI. These included reducing rejection after transplantation, treating inflammatory diseases, and reducing chronic failure of the liver, kidney, and heart. The techniques included TD cannulation and lymphovenuous fistula. The outcomes were variable and often equivocal, and this appears to reflect poor design quality. There is clinical equipoise regarding a therapeutic role of (TD lymph drainage in acute pancreatitis, and probably other acute diseases.

CONCLUSIONS

Until well-designed clinical trials are undertaken, the clinical benefits of TDIs will remain promising, but uncertain.

Clinical applications and complications of umbilical vein cannulation

Cannulation of the obliterated umbilical vein provides direct access to the portal venous circulation; by this means the portal venous pressure may be measured and venography performed to demonstrate the anatomy of the intra- and extrahepatic portal venous system and the presence of space-occupying lesions within the liver. Following dilatation the umbilical vein may also be used for temporary or permanent decompression of the portal system in patients with portal hypertension and bleeding oesophageal varices.

The technique of cannulation of the umbilical vein is described. The results of attempted umbilical vein cannulation in 26 patients are reported; in 16 for the investigation or treatment of portal hypertension and in 10 for the diagnosis of suspected space-occupying lesions in the liver. Cannulation was successful in 12 patients: the reasons for failure and the complications of the technique are described. One patient with bleeding oesophageal varices was treated by a shunt between the umbilical vein and the upturned saphenous vein; the shunt functioned initially but later thrombosed, possibly owing to insufficient dilatation of the umbilical vein.

The value of and indications for umbilical vein cannulation are discussed. The procedure may be technically difficult and is not free of complications, but can give valuable information in selected patients with portal hypertension and in patients with suspected, intrahepatic, space-occupying lesions. The high failure rate in this series may be related to initial lack of experience with the technique.

Management of bleeding oesophageal varices by draining lymph from the thoracic duct

The thoracic duct was cannulated in six patients who were actively bleeding from varices and had not responded to conservative treatment but draining lymph from the thoracic duct did not control bleeding in five patients. There was no drop in intrasplenic pulp pressure following this procedure when recorded in three of these patients. Bleeding stopped in one patient after lymph had been drained for nine and a half hours, and there was only a modest change in intrasplenic pressure. The therapeutic use of this technique to control oesophageal varices could not be substantiated.