Renal transplantation after thoracic duct drainage

Lymphangiography and Lymphatic Interventions

Compared with the traditional pedal lymphangiography, intranodal lymphangiography and MR lymphangiography have made imaging of the lymphatic system less challenging. Improvements in imaging and availability of newer catheters have allowed embolization of lymphatic system much more feasible that previously envisioned. In this article, we briefly review the anatomy, imaging, and current and future of lymphatic interventions.

Modern Techniques of Lymphangiography and Interventions: Current Status and Future Development

One of the crucial functions of the lymphatic system is maintenance of fluid balance. Nonetheless, due to lack of clinical imaging and interventional techniques, the lymphatic system has been under the radar of the medical community. The recently developed intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography provide new insight into lymphatic pathology. Thoracic duct embolization has become the method of choice for the treatment of patients with chylous leaks. Interstitial lymphatic embolization further expanded the lymphatic embolization approaches. Liver lymphatic lymphangiography and embolization allow treatment of postsurgical liver lymphorrhea and protein-losing enteropathy. The potential for further growth of lymphatic interventions is vast and includes liver lymphatic procedures and advanced thoracic duct interventions, such as thoracic duct externalization and stenting. These current and future advances will open up a realm of new treatments and diagnostic opportunities.

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.

Thoracic Duct Narrowing-Innovative Technique Restraining Weight Gain in Rats

BACKGROUND

The lymphatic system is responsible for the absorption of fats from the digestive system, conveying 60-70 % of ingested fat to the blood stream. From the anatomical point of view, all the lymphatic drainage from the lower half of the body converges in the abdomen to enter the thoracic duct. This experimental study aim was to study the result of thoracic duct narrowing (TDN), an innovative surgical technique, on weight gain restrain in high-fat diet-fed rats.

METHODS

Forty-seven rats were allocated into three groups: thoracic duct narrowing ("S"-surgery), sham operation ("CS"-control surgery), and no surgery ("C"-control). All rats were fed with high-fat, cholesterol-rich diet. Food consumption and metabolic syndrome parameters including weight gain, plasma lipids and glucose, blood pressure, and viscera weight and histopathology were analyzed.

RESULTS

Thoracic duct narrowing was proved simple and safe surgical procedure in the rat model. TDN induced weight gain restrain, associated with mild hepatic steatosis compared to moderate-severe hepatic steatosis in control groups. Splenomegaly and splenic fatty histiocytes were shown in the treated animals.

CONCLUSIONS

TDN improved several parameters of the metabolic syndrome in high-fat diet-fed rats. TDN carries the potential of innovative obesity treatment using the lymphatic route of lipid absorption.

Near-infrared lymphography as a minimally invasive modality for imaging lymphatic reconstitution in a rat orthotopic hind limb transplantation model

Wider application of vascularized composite allotransplantation (VCA) is limited by the need for chronic immunosuppression. Recent data suggest that the lymphatic system plays an important role in mediating rejection. This study used near-infrared (NIR) lymphography to describe lymphatic reconstitution in a rat VCA model. Syngeneic (Lewis-Lewis) and allogeneic (Brown Norway-Lewis) rat orthotopic hind limb transplants were performed without immunosuppression. Animals were imaged pre- and postoperatively using indocyanine green (ICG) lymphography. Images were collected using an NIR imaging system. Co-localization was achieved through use of an acrylic paint/hydrogen peroxide mixture. In all transplants, ICG first crossed graft suture lines on postoperative day (POD) 5. Clinical signs of rejection also appeared on POD 5 in allogeneic transplants, with most exhibiting Grade 3 rejection by POD 6. Injection of an acrylic paint/hydrogen peroxide mixture on POD 5 confirmed the existence of continuous lymphatic vessels crossing the suture line and draining into the inguinal lymph node. NIR lymphography is a minimally invasive imaging modality that can be used to study lymphatic vessels in a rat VCA model. In allogeneic transplants, lymphatic reconstitution correlated with clinical rejection. Lymphatic reconstitution may represent an early target for immunomodulation.

Could a simple surgical intervention eliminate HIV infection?

BACKGROUND

Human Immunodeficiency Virus (HIV) infection is a dynamic interaction of the pathogen and the host uniquely defined by the preference of the pathogen for a major component of the immune defense of the host. Simple mathematical models of these interactions show that one of the possible outcomes is a chronic infection and much of the modelling work has focused on this state.

BIFURCATION

However, the models also predict the existence of a virus-free equilibrium. Which one of the equilibrium states the system selects depends on its parameters. One of these is the net extinction rate of the preferred HIV target, the CD4+ lymphocyte. The theory predicts, somewhat counterintuitively, that above a critical extinction rate, the host could eliminate the virus. The question then is how to increase the extinction rate of lymphocytes over a period of several weeks to several months without affecting other parameters of the system.

TESTING THE HYPOTHESIS

Proposed here is the use of drainage, or filtration, of the thoracic duct lymph, a well-established surgical technique developed as an alternative for drug immunosuppression for organ transplantation. The performance of clinically tested thoracic duct lymphocyte depletion schemes matches theoretically predicted requirements for HIV elimination.

Influences of thoracic duct blockage on early enteral nutrition for patients who underwent esophageal cancer surgery

OBJECTIVES

We have previously reported the beneficial effects of immediate enteral nutrition (EN) after esophageal cancer surgery. This randomized control study was conducted to determine whether immediate EN is beneficial or not for patients whose thoracic ducts were ligated, as well as those whose thoracic ducts were preserved.

PATIENTS AND METHODS

Thirty-nine patients who underwent radical resection of the esophageal cancer entered this trial. After stratifying into two groups--patients whose thoracic ducts were preserved [D(+)] and those whose thoracic ducts were ligated [D(-)], they were randomly divided into two groups--the patients who received early EN and those who received parenteral nutrition (PN) followed by delayed enteral feeding. Thus, the number of patients in the D(+)-EN group, D(+)-PN group, D(-)-EN group and D(-)-PN group were 13, 12, 7 and 7, respectively. The mortality and morbidity rates, and several blood chemistries were compared between the EN groups and the PN groups.

RESULTS

Total lymphocyte count showed a significant early increase and serum c-reactive protein (CRP) was significantly decreased in the D(+)-EN group compared to the D(+)-PN group. However those differences were not observed between the D(-) groups. Serum total bilirubin was significantly decreased in the both EN groups compared to the PN groups. The mortality and morbidity rates were not different between the EN group and the PN group in the D(+) patients and also in the D(-) patients.

CONCLUSIONS

Patients whose thoracic ducts were ligated did not obtain any other benefit from early enteral feeding except for bilirubin metabolism. Early enteral feeding is not recommended for patients whose thoracic ducts are ligated during radical resection of a cancer in the thoracic esophagus.

Entry of gut lymph into the circulation primes rat neutrophil respiratory burst in hemorrhagic shock

OBJECTIVE

Endothelial cell injury by polymorphonuclear neutrophil (neutrophil [PMN]) respiratory burst after trauma and hemorrhagic shock (T/HS) predisposes subjects to acute respiratory distress syndrome and multiple organ failure. T/HS mesenteric lymph injures endothelial cell and lymph duct ligation (LDL) before T/HS prevents pulmonary injury. We investigated the role of mesenteric lymph in PMN priming by T/HS.

DESIGN

Prospective experiment in rats.

SETTING

University hospital laboratory.

SUBJECTS

Adult male rats.

INTERVENTIONS

Mesenteric lymph was obtained from rats undergoing T/HS (30 mm Hg, 90 mins) or sham shock (T/SS). Plasma was harvested from uninstrumented control (UC), T/HS, T/SS, and T/HS+LDL rats. PMNs were isolated from UC, T/HS, and T/HS+LDL rats.

MEASUREMENTS AND MAIN RESULTS

PMNs from UC rats were incubated in buffer, 1% T/HS lymph, and 1% T/SS lymph. PMNs from UC rats were incubated in UC, T/HS, T/SS, and T/HS+LDL plasma. PMN respiratory burst was initiated by using macrophage inflammatory protein (MIP)-2/platelet-aggregating factor (PAF) or phorbol myristate acetate. Cytosolic calcium ([Ca2+]i) responses to MIP-2/PAF were assayed in PMN from UC, T/HS, and T/HS+LDL rats. PMN preincubated in T/HS lymph showed significant elevations in MIP/PAF-elicited respiratory burst compared with T/HS lymph or buffer only (p <.05; analysis of variance/Tukey's test). T/HS lymph incubation also increased (p <.05) phorbol myristate acetate elicited respiratory burst compared with buffer or T/SS. Preincubation in T/HS plasma increased MIP-2/PAF-elicited respiratory burst (p <.05) compared with UC or T/SS plasma. LDL blocked T/HS priming of respiratory burst. Control PMN [Ca2+]i responses to MIP-2 and PAF were low. T/SS PMN were significantly more responsive, but the T/HS PMN showed still higher responses (p <.01). LDL reversed the priming of [Ca2+]i responses by T/HS (p <.01).

CONCLUSIONS

PMNs are primed by T/HS lymph but not T/SS lymph and by T/HS plasma but not T/SS plasma. LDL before shock prevents T/HS plasma from priming PMN. The magnitude of respiratory burst found here paralleled the [Ca2+]i responses seen to receptor dependent initiating agonists. Mesenteric lymph is both necessary and sufficient to prime PMN after T/HS in the rat, and it primes PMN in part by enhancing [Ca2+]i responses to G-protein coupled chemoattractants. Mesenteric lymph mediates postshock PMN dysfunction.

Management of thoracic duct injuries after oesophagectomy

BACKGROUND

Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment.

METHODS

The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available.

RESULTS

Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50-82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10-16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax.

CONCLUSION

The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails.

Transplantation of tissues and organs. Review of the first 100 years of the Southern Surgical Association

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