Reduced intestinal protein loss in Crohn's disease after lymphovenous anastomosis

In a 27-year-old patient suffering from Crohn's disease covering nearly the entire small intestine, the major problem was a marked protein-losing enteropathy which required long-term intravenous replacement. Accidentally, we disclosed a dilated thoracic duct with incompetent valves and stenosis at the junction into the subclavian vein in this patient. To reduce the intestinal protein loss, an anastomosis was performed between the thoracic duct and the internal jugular vein. Subsequently the intestinal protein loss dropped from 40 to 26% and replacement of proteins could be reduced. The patient was observed for 4 years postoperatively and the therapeutic effect continued. Besides this therapeutic aspect, the present case gives cause to consider the possible role of the lymphatics in the pathogenesis of Crohn's disease.

Surgical treatment of portal hypertension in China

In 3,263 cases of portal hypertension, various methods of porta-systemic shunt or portal-azygous disconnection were applied with reasonable results. In addition to the treatment for intractable ascites, peritoneal-jugular shunt and thoracic duct jugular anastomosis were employed in 132 cases. This is our approach to portal hypertension in the big city hospitals. There is much controversy over the suitability of prophylactic surgery and the ideal time for surgery. The reasons for prophylactic surgery and the management of bleeding varices are discussed in this paper.

Surgical management of persistent postoperative chylothorax in children

Chylothorax occurring postoperatively in children is found most commonly after cardiovascular operations, but may occur after almost any thoracic procedure. Seven cases of postoperative chylothorax seen at the Children's Hospital of Eastern Ontario in Ottawa from 1976 to 1983 are reported. Two resolved with nonoperative management and five required surgical intervention. The authors discuss the clinical presentation, treatment and outcome. They describe a simple, safe and effective method of ligation of the thoracic duct just above the diaphragm.

Transhiatal esophagectomy without thoracotomy for carcinoma of the thoracic esophagus

Transhiatal esophagectomy (THE) without thoracotomy was performed in 100 patients with carcinoma of the thoracic esophagus (7 upper, 45 mid, and 48 lower third). The esophagus was replaced with stomach (96) or colon (4). Intraoperative complications included pneumothorax requiring a chest tube(s) (63) and membranous tracheal tear (2). Blood loss averaged 880 ml. Postoperative complications included transient recurrent laryngeal nerve paresis (31), anastomotic leak (5), and chylothorax (2). There were no intraoperative deaths or re-explorations for postoperative bleeding. Six hospital deaths resulted from aspiration pneumonia (2), retroperitoneal or mediastinal abscess (2), pulmonary embolus (1), and respiratory insufficiency (1). Postoperative hospitalization averaged 14 days. Actuarial survival among the 94 operative survivors is 82% at 6 months, 52% at 12 months, 32% at 24 months, 22% at 36 months, and 17% at 48 months. Of the operative survivors, 15% have lived 2 years or more and 10% are clinically disease free. THE is safe, associated with a low morbidity, and achieves excellent palliation and survival at least as good as that reported in many series of transthoracic esophagectomies for esophageal carcinoma.

A critical re-appraisal of lymph-venous shunt in the management of massive ascites

Lymph-venous shunt is one of most investigated procedures in the management of intractable ascites. However, there is considerable variation in the reported results. Personal experience with twenty-one operated cases reveals a dubious role for this intervention. Frequent anatomical variations and uncertain role and incidence of duct-end stenosis, in our opinion, reduces the efficacy of the procedure.

Experimental remarks on the utilization of biological tissue adhesives in lymphovenous anastomosis

The present experimental study deals with the utilization of biological tissue adhesives in an effort to estimate their value in lympho-venous anastomoses. The entire experimental work was carried out on 8 dogs, using the thoracic duct and the jugular vein for a lympho-venous anastomosis. The study also describes the experimental steps and overall technique. The anastomoses were carried out in an end to side fashion with four stitches and were completed with a biological adhesive substance later ( Fibrinkleber ). All the anastomoses were re-investigated for occlusion, formation of thrombus or a lymphatic fistula. There were no deaths. One of the anastomoses was occluded by a thrombus but no fistula was found in any of the dogs. The above results indicate that biological adhesive substances can be used satisfactorily as an adhesive substance in lymphovenous anastomosis.

Congenital chylothorax: management by ligature of the thoracic duct

Congenital chylothorax in a male infant persisted for 10 weeks despite repeated thoracocenteses and dietary regimens which included total parenteral nutrition for 37 days and a peroral semielementary diet with medium-chain triglyceride content for 19 days. Thoracotomy disclosed a small leak in the thoracic duct. The duct was ligated above and below the leak, as attempted repair was unsuccessful. There was no recurrence of pleural effusion after the operation and no distal lymphoedema was observed.

[Effect of drainage of the thoracic duct with lymphosorption on the lymphocyte number in the blood and lymph]

Having studied the amount and quality of lymphocytes in the blood and lymph of 48 patients the authors have established that loss of great amount of small lymphocytes during the three-days drainage of the thoracic lymph duct was completely compensated at the expense of reserve populations. Drainage prolonged up to 5-6 days results in exhaustion of the circulating pool of small lymphocytes and changes in immune reactivity. The latter however are not followed by a sharply decreased antibacterial resistance of the organism.

Thoracic duct and right lymphatic duct: surgical approaches for drainage in the canine with comparison of cellular and chemical contents

The technics of drainage of the right lymphatic duct (RD) and thoracic duct (TD) used in our laboratory have been described and illustrated. In two series of experiments the components of RD and of TD lymph were compared to blood plasma collected concurrently. RD and TD lymph, collected concurrently, were also compared in a third series. RD and TD lymph differ in a number of ways including rate of flow, enzyme activity, cell count and lipid-electrophoretic patterns. The limitations of RD lymph for the study of fluid and protein dynamics of the lungs and the cell population of lung lymph are outlined. Higher levels of enzyme activity in RD compared to TD lymph have been noted. This phenomena appears to depend on a number of complex factors.

[Controlled drainage of the thoracic lymph duct]

A surgical technique and experience with the clinical employment of catheterization of the thoracic lymph duct with the help of silicon cannulae are described. The method of catheterization of the thoracic lymph duct allows controlling the day volume of the lymph loss and prevents different clinical manifestations of lymphostasis in the nearest postoperative period.

An experimental model for simultaneous chronic sampling of portal and systemic blood and gastrointestinal lymph via cannulae in conscious swine

Surgical techniques are described whereby safe chronic cannulations of the portal vein, the external iliac artery and vein and the cisterna chyli of pigs were performed. The pigs tolerated the operations well and there was a short recovery period. They were unrestrained during the subsequent feeding experiments, when large sequential blood and lymph samples were withdrawn readily. The experimental periods varied from 3 to 46 days (mean : 13.4 days, SE: 2.0). All of 22 arterial cannulae remained patent (mean : 16 days, SE : 2.2), nineteen of 22 portal cannulae (mean : 15 days, SE : 1.8) and eighteen of 22 venous cannulae (mean : 14 days, SE : 1.9). The lymph cannula patency varied from 2 to 7 days, but lymph samples were easily obtained through all but one of them during the third postoperative day.

[Variations of internal drainage of the thoracic duct in cirrhosis of the liver]

The experience with 100 operations of the internal drainage of the thoracic lymphatic duct has shown technical difficulties of the procedure. In relation with concrete topographo-anatomical conditions the authors recommend to use reimplantation of the thoracic lymphatic duct and plastic operations on its orifice in addition to the lymphovenous anastomosis. Their technique is described.