Significance of disturbed lymph flow for the pathogenesis of pancreatitis. I. Ligature of the ductus thoracicus in the rat

To examine the significance of a disturbed lymph drainage for the pathogenesis of acute necrotizing pancreatitis, thoracic duct ligation was performed in 53 Wistar rats. Histological examination of the pancreas and analysis of serum lipase and serum amylase were carried out at various time intervals from 1 h to 42 days after initiating the experiment. Sudden stop of the lymph flow induced a long lasting pancreatic edema, initially in the perilobular interstitium and eventually also within some lobules, with scattered necroses of whole acini or single acinar cells mainly in the peripheral zones of the lobuli. In addition, a marked interstitial inflammatory infiltrate developed, resembling lipophage granulomas. This was most likely due to alymphangeal reflux of sunflower oil, applicated for the visualization of the thoracic duct. These findings suggest that changes in the lymph flow may favour the development of acute necrotizing pancreatitis.

Transdiaphragmatic approach to thoracic duct ligation in the cat

An approach combining ventral midline celiotomy with transdiaphragmatic thoracotomy was evaluated in eight healthy cats for ligation of the thoracic duct system. Evans Blue solution was injected into the right colic lymph node to outline the intestinal lymphatic trunk and the thoracic duct system. Three cats (group 1) had mesenteric lymphangiograms and three (group 2) had only lymph node dye injection before thoracic duct ligation. The thoracic duct system was ligated with hemostatic clips just cranial to the aortic hiatus of the diaphragm, through a left transdiaphragmatic thoracotomy. Two cats (group 3) had prethoracotomy mesenteric lymphangiograms and thoracic duct isolation without ligation. Mesenteric lymphangiography was performed immediately after the surgery. In all of the cats, an absence of contrast medium in the thoracic duct system cranial to the surgical site was interpreted as complete obstruction. Four weeks after ligation, there was complete obstruction of the thoracic duct system with alternate lymphaticovenous communications in four of the six cats with ligated thoracic duct systems. Partial obstruction of the thoracic duct system with alternate lymphaticovenous communications was present in the other two cats. Both cats without thoracic duct ligation had patent thoracic duct systems. At necropsy of the six cats with ligated thoracic ducts, there was mild focal lymphadenitis of injected lymph nodes in three cats. The wall of the aorta adjacent to the hemostatic clips was normal in all six cats. The surgical technique was simple and provided excellent exposure. Vital staining with Evans Blue helped visualize the thoracic duct system, but mesenteric lymphangiography did not. Postligation lymphangiography was not of value in identifying incomplete ligation.

The beneficial effects of thoracic duct drainage in HLA-1 haplotype identical kidney transplantation

The beneficial effects of pre-treatment thoracic duct drainage on graft survival in living related kidney transplantation are presented. Since July 1980 lymphocyte depletion through thoracic duct drainage has been used as pre-treatment therapy in 39 HLA-1 haplotype identical living related kidney transplant patients. Thoracic duct drainage was maintained for 29 to 49 days (mean 36 days) before transplantation and 52 to 215 times 10(9) cells (mean 130 times 10(9) cells) were removed. Postoperative immunosuppression consisted of azathioprine and steroids. Actuarial graft survival was 100 per cent at 3 months, 97 per cent at 6 months through 2 years, 92 per cent at 3 years and 57 per cent at 4 years after transplantation. Patient survival was 100 per cent at 3 months, 97 per cent at 6 months through 3 years and 86 per cent at 4 years. Pre-treatment thoracic duct drainage maintained for more than 28 days could have a significant role on the improvement of the graft survival in HLA-1 haplotype identical kidney transplantation.

Simultaneous occurrence of chylothorax and subarachnoid pleural fistula after thoracotomy

A left chylothorax complicated elective left posterolateral thoracotomy and emergency decompressive laminectomy carried out on a 32-year-old woman with a benign neurofibroma. Failure of conservative therapy necessitated ligation of the thoracic duct and this in turn unmasked the concomitant subarachnoid-pleural fistula. Surgical repair and lumbar subarachnoid drainage were required to close the second fistula. The clinical setting, diagnosis and management of this uncommon condition are reviewed.

Thoracic duct lymph and PEEP studies in anaesthetized dogs. II. Effect of a thoracic duct fistula on the development of a hyponcotic-hydrostatic pulmonary oedema

PEEP impedes thoracic duct drainage (LF). This can be counteracted by a thoracic duct fistula. Consequently, lung oedema (LOE) should develop during PEEP more slowly with LF at atmospheric pressure (LFAP) than with LF against jugular venous pressure (LFJVP). In 12 anaesthetized dogs LOE was produced by Ringer's solution i.v. (2.5 ml/min per kg) for 6 h during PEEP (10 mmHg) with either LFAP or LFJVP. Ringer's + PEEP greatly increased aortic, pulmonary artery and wedge pressures, JVP, and cardiac output. Colloid osmotic pressures in plasma and lymph were drastically reduced, pulmonary effective filtration pressure (EFP) rose by about 20 mmHg. LFJVP increased 7-fold, LFAP about 19-fold, the respective loss of plasma proteins was 1.83 and 1.06 g/kg during 6 h. Thermal-dye extravascular lung water showed an increment of 68 with LFJVP versus 43 microliter/h/g per mmHg with LFAP. Final lung water content was at any delta EFP (12.8-31.9 mmHg) lower with LFAP than with LFJVP amounting 512 with LFJVP versus 377 microliters/g/per mmHg with LFAP. LFAP decreased the development of LOE during PEEP by bypassing the PEEP-induced high JVP and thus facilitating the removal of interstitial fluid. It is hypothesized that a thoracic duct fistula might aid the treatment of patients with LOE due to ARDS and therefore requiring high levels of PEEP.

Management of intractable pleural effusion in a dog with pleuroperitoneal shunt

Persistent nonchylous pleural effusion followed thoracic duct ligation for chylothorax in a dog. Attempts at tetracycline pleurodesis twice failed to reduce the quantity of pleural effusion. Repeated thoracentesis caused malnutrition and hypoproteinemia. A modified Denver peritoneal-venous shunt was implanted to internally drain the pleural fluid into the peritoneal cavity. Normal body weight and plasma protein concentration were regained in 40 days. Digital compression of the pump chamber alleviated the signs of respiratory compromise, without complication. At 50 weeks post-installation, a proteinaceous clot obstructed the original efferent pump valve, necessitating shunt replacement. Eight weeks after replacement, the dog was asymptomatic.

'Chyloma': a persistent post-traumatic collection in the left supraclavicular region

A patient with traumatic disruption of the thoracic duct resulting in a chylothorax and a 'chyloma' in the left supraclavicular region is described. Supradiaphragmatic ligation of the thoracic duct was necessary for treatment of the chyloma.

[Injuries of the thoracic duct during neck surgery]

Although rarely published, operative injuries to thoracic duct in neck are by no means exceptional, and can occur during all types of surgery to lower cervical and supraclavicular regions. A case is reported and used as a basis for an analysis of diagnostic means and therapeutic possibilities of injuries detected during operation or those developing manifestations at a later stage. In the case reported, long-term medical treatment resulted in arrest of lymphorrhea within 37 days.

[Primary and secondary chylopericardium]

Primary chylopericardium proved to be the (rare) cause of chronic, symptom-poor pericardial effusion in a 19-year-old man. Echocardiography and pericardiocentesis provided a firm diagnosis. Lymphography demonstrated extravasation into the mediastinum but no direct connection into the pericardial sac. Ligation of the thoracic duct at diaphragmatic level and pericardiostomy achieved a cure. Secondary chylopericardium requires treatment of the underlying disease, e.g. mediastinal tumor. Chylopericardium after thoracic or cardiac operation without signs of tamponade is preferably treated conservatively by pericardiocentesis and diet.

Postpneumonectomy tension chylothorax

Chylous leak from the thoracic duct into the pleural space may occur after any type of thoracic surgery. This is a serious, often life-threatening entity. Two cases of postpneumonectomy chylothorax with hemodynamic compromise are reported. Early recognition, pathophysiology, and optimal management of this problem are discussed.

Xerostomia. A treatment feasibility study in dogs

An acute study was performed in dogs to test the feasibility of using another bodily fluid in place of saliva in patients with xerostomia. Chyle was routed from the thoracic duct to the oral cavity via a vein graft using the external jugular vein. While technically challenging, the vein conduit worked well in delivering chyle to the oral cavity.

[Chylopericardium as a rare cause of a "large" heart shadow--2 case reports]

Two cases with the diagnosis of asymptomatic chylopericard were evaluated. One was a 20-year old girl who had been operated on for intrathoracic lymphangioma and chylopericardium that existed since birth, and who developed a chylothorax after the operation. The second case report concerns a 22-year old man who had been suffering from a posttraumatic asymptomatic chylopericardium for two years and who is being treated conservatively "Low-fat diet").

[Effect of draining the thoracic lymph duct on the protein level of blood and lymph in peritonitis]

Under study were specific features of protein metabolism in 52 patients with peritonitis treated by routine methods. In 26 of them the external lymph drainage was used with a compensation of lymph loss. Lymph drainage in peritonitis results in detoxication of organism and normal protein-synthesizing function of the liver.

The effects of stress in normal and adrenalectomized mice

Many of the present concepts in lymphocyte physiology were established using experimental protocols involving surgery in cortico-sensitive rodents. In the present report we demonstrate that commonly used operative procedures in mice result in a depletion of 50-90% of cells from primary or secondary lymphoid organs 24 to 48 postsurgery. Adrenalectomy, by itself, induces considerable depletion, and does not abolish the effects of stress in lymphocyte populations. These findings indicate that questions concerning the dynamics of production renewal rate and life-span of lymphocytes cannot be investigated by approaches involving surgery in the mouse.

[Alkaline phosphatase in the blood and lymph in diffuse peritonitis]

Activity of alkaline phosphatase was studied in blood and lymph of 52 dogs with experimental peritonitis and in 26 patients with the drained thoracic duct and in 26 patients without lymphodrainage. Pronounced enzyme intoxication was revealed. Under physiological conditions alkaline phosphatase is transported by both blood and lymphatic bed. In peritonitis the lymphatic route of the enzyme transport gets considerably greater. Drainage of the thoracic duct gives good detoxicating effect (decreased alkaline phosphatase activity).