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Moazzam S, O'Hagan LA, Clarke AR, Itkin M, Phillips ARJ, Windsor JA, Mirjalili SA. The cisterna chyli: a systematic review of definition, prevalence, and anatomy. Am J Physiol Heart Circ Physiol 2022; 323:H1010-H1018. [PMID: 36206050 DOI: 10.1152/ajpheart.00375.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The cisterna chyli is a lymphatic structure found at the caudal end of the thoracic duct that receives lymph draining from the abdominal and pelvic viscera and lower limbs. In addition to being an important landmark in retroperitoneal surgery, it is the key gateway for interventional radiology procedures targeting the thoracic duct. A detailed understanding of its anatomy is required to facilitate more accurate intervention, but an exhaustive summary is lacking. A systematic review was conducted, and 49 published human studies met the inclusion criteria. Studies included both healthy volunteers and patients and were not restricted by language or date. The detectability of the cisterna chyli is highly variable, ranging from 1.7 to 98%, depending on the study method and criteria used. Its anatomy is variable in terms of location (vertebral level of T10 to L3), size (ranging 2-32 mm in maximum diameter and 13-80 mm in maximum length), morphology, and tributaries. The size of the cisterna chyli increases in some disease states, though its utility as a marker of disease is uncertain. The anatomy of the cisterna chyli is highly variable, and it appears to increase in size in some disease states. The lack of well-defined criteria for the structure and the wide variation in reported detection rates prevent accurate estimation of its natural prevalence in humans.
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Affiliation(s)
- Sara Moazzam
- School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Lomani A O'Hagan
- School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Alys R Clarke
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Maxim Itkin
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anthony R J Phillips
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - S Ali Mirjalili
- Department of Anatomy and Medical Imaging, The University of Auckland, Auckland, New Zealand
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2
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Windsor JA, Trevaskis NL, Phillips AJ. The Gut-Lymph Model Gives New Treatment Strategies for Organ Failure. JAMA Surg 2022; 157:540-541. [PMID: 35442412 DOI: 10.1001/jamasurg.2022.0654] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical Health Sciences, University of Auckland, Auckland, New Zealand
| | - Natalie L Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Anthony J Phillips
- Surgical and Translational Research Centre, Faculty of Medical Health Sciences, University of Auckland, Auckland, New Zealand.,School of Biological Sciences, Faculty of Science, University of Auckland, Auckland, New Zealand
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3
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Escott ABJ, Hong J, Connor BN, Phang KL, Holden AH, Phillips ARJ, Windsor JA. Sampling Thoracic Duct Lymph After Esophagectomy: A Pilot Study Investigating the "Gut-Lymph" Concept. Lymphat Res Biol 2021; 20:260-274. [PMID: 34582739 DOI: 10.1089/lrb.2019.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction: Gut-lymph in animal models of acute disease is altered by intestinal ischemia and contributes to the development of systemic inflammation and organ dysfunction. Investigating gut-lymph in humans is hampered difficulty in accessing the thoracic duct (TD) for lymph sampling. The aims of this study were to develop and pilot a technique of intraoperative TD cannulation with delayed embolization to serially measure TD lymph pressure, flow, and composition (including markers of intestinal injury) during the early postoperative period and in response to enteral feeding and vasopressor treatment. Methods: A Seldinger technique was used for percutaneous TD cannulation during an Ivor Lewis esophagogastrectomy. Lymph flow rate and pressure were measured. TD lymph and plasma were sampled at 12 hourly intervals for up to 120 hours after surgery and before TD embolization. Biochemistry, lipids, cytokines, and markers of intestinal injury were measured before and after enteral feeding commenced at 36 hours. Results: Intraoperative TD cannulation was technically feasible in three of four patients. Delayed TD embolization was only successful in one of three patients, with two patients requiring a re-thoracotomy to treat chylothorax. Profound changes in TD composition, but not flow rate, occurred over time and in response to enteral feeding and vasopressors. TD lymph compared with plasma had significantly higher lipase (1.4-17 × ), interleukin-6 (8-108 × ), tumor necrosis factor-α (2.7-17 × ), d-lactate (0.3-23 × ), endotoxin (0.1-41 × ), and intestinal fatty acid binding protein (1.1-853 × ). Conclusions: Although TD cannulation and lymph sampling were successful, TD embolization failed in two of three patients. The composition of sampled TD lymph changed dramatically in response to enteral feeding, indicating intestinal ischemia that could be exacerbated by nonselective vasopressors. The higher concentration of proinflammatory cytokines and gut injury markers in TD lymph, compared with plasma, lends support to the gut-lymph concept.
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Affiliation(s)
| | - Jiwon Hong
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences and Surgical and Translational Research Centre, University of Auckland, Auckland, New Zealand
| | - Brigid Nancy Connor
- Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Kian Liun Phang
- North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Andrew Hugh Holden
- Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Anthony Ronald John Phillips
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences and Surgical and Translational Research Centre, University of Auckland, Auckland, New Zealand
| | - John Albert Windsor
- Department of Surgery, Surgical and Translational Research Centre, University of Auckland, Auckland, New Zealand
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Xiu G, Li X, Yin Y, Li J, Li B, Chen X, Liu P, Sun J, Ling B. SDF-1/CXCR4 Augments the Therapeutic Effect of Bone Marrow Mesenchymal Stem Cells in the Treatment of Lipopolysaccharide-Induced Liver Injury by Promoting Their Migration Through PI3K/Akt Signaling Pathway. Cell Transplant 2021; 29:963689720929992. [PMID: 32452221 PMCID: PMC7563832 DOI: 10.1177/0963689720929992] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Mesenchymal stem cells (MSCs) are thought to have great potential in the therapy of acute liver injury. It is possible that these cells may be regulated by the stromal cell-derived factor-1 (SDF-1)/CXC chemokine receptor-4 (CXCR4) signaling axis, which has been shown to promote stem cells migration in the inflammation-associated diseases. However, the effects of SDF-1/CXCR4 axis on the MSCs-transplantation-based treatment for acute liver injury and the underlying mechanisms are largely unknown. In this study, we sought to determine whether SDF-1/CXCR4 would augment the therapeutic effect of bone marrow mesenchymal stem cells (BMSCs) by promoting their migration, which may result from activating the phosphoinositide 3-kinase (PI3K)/Akt signaling pathway, in a rat acute liver injury model induced by lipopolysaccharide (LPS). We found that BMSCs transplantation markedly attenuated liver injury and improved the survival of LPS-treated rats. Of interest, overexpression of CXCR4 in BMSCs could substantially promote their migration both in vitro and in vivo, and result in even better therapeutic effects. This might be attributed to the activation of PI3K/Akt signaling pathway in BMSCs that is downstream of CXCR4, as demonstrated by the use of the CXCR4 antagonist AMD3100 and PI3K pathway inhibitor LY294002 assays in vitro and in vivo. Together, our results unraveled a novel molecular mechanism for the therapeutic effect of BMSCs for the treatment of acute liver injury, which may shed a new light on the clinical application of BMSCs for acute liver failure.
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Affiliation(s)
- Guanghui Xiu
- Department of Intensive Care Unit, The Second People's Hospital of Yunnan Province (The Fourth Affiliated Hospital of Kunming Medical University), Kunming, Yunnan Province, China.,These authors contributed equally to this article
| | - Xiuling Li
- Department of Obstetrics, The First People's Hospital of Yunnan province, Kunming, Yunnan Province, China.,These authors contributed equally to this article
| | - Yunyu Yin
- Department of Intensive Care Unit, The Affiliated hospital of North Sichuan Medical College, Nanchong, Sichuan Province, China.,These authors contributed equally to this article
| | - Jintao Li
- The Institute of Neuroscience, The Kunming Medical University, Kunming, Yunnan Province, China
| | - Bingqin Li
- Department of Intensive Care Unit, The Second People's Hospital of Yunnan Province (The Fourth Affiliated Hospital of Kunming Medical University), Kunming, Yunnan Province, China
| | - Xianzhong Chen
- Department of Intensive Care Unit, The Second People's Hospital of Yunnan Province (The Fourth Affiliated Hospital of Kunming Medical University), Kunming, Yunnan Province, China
| | - Ping Liu
- Department of Intensive Care Unit, The Second People's Hospital of Yunnan Province (The Fourth Affiliated Hospital of Kunming Medical University), Kunming, Yunnan Province, China
| | - Jie Sun
- Department of Intensive Care Unit, The Second People's Hospital of Yunnan Province (The Fourth Affiliated Hospital of Kunming Medical University), Kunming, Yunnan Province, China
| | - Bin Ling
- Department of Intensive Care Unit, The Second People's Hospital of Yunnan Province (The Fourth Affiliated Hospital of Kunming Medical University), Kunming, Yunnan Province, China
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5
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Itkin M, Rockson SG, Witte MH, Burkhoff D, Phillips A, Windsor JA, Kassab GS, Hur S, Nadolski G, Pabon-Ramos WM, Rabinowitz D, White SB. Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2021; 32:762.e1-762.e7. [PMID: 33610432 DOI: 10.1016/j.jvir.2021.01.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/06/2021] [Accepted: 01/16/2021] [Indexed: 11/26/2022] Open
Abstract
Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.
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Affiliation(s)
- Maxim Itkin
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Stanley G Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marlys H Witte
- University of Arizona College of Medicine Tucson Arizona, International Society of Lymphology, Tuscon, Arizona
| | | | - Anthony Phillips
- Applied Surgery and Metabolism Laboratory, Surgical and Translational Research Centre, School of Biological Sciences & Dept. of Surgery, Auckland University, Auckland, New Zealand
| | - John A Windsor
- Surgery and Director Surgical and Translational Research Centre, University of Auckland, New Zealand
| | | | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Gregory Nadolski
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Waleska M Pabon-Ramos
- Pediatric Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Debbie Rabinowitz
- Department of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Radiology and Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware
| | - Sarah B White
- Clinical Research and Registries Division, SIR Foundation, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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6
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Trevaskis NL, Lee G, Escott A, Phang KL, Hong J, Cao E, Katneni K, Charman SA, Han S, Charman WN, Phillips ARJ, Windsor JA, Porter CJH. Intestinal Lymph Flow, and Lipid and Drug Transport Scale Allometrically From Pre-clinical Species to Humans. Front Physiol 2020; 11:458. [PMID: 32670074 PMCID: PMC7326060 DOI: 10.3389/fphys.2020.00458] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022] Open
Abstract
The intestinal lymphatic system transports fluid, immune cells, dietary lipids, and highly lipophilic drugs from the intestine to the systemic circulation. These transport functions are important to health and when dysregulated contribute to pathology. This has generated significant interest in approaches to deliver drugs to the lymphatics. Most of the current understanding of intestinal lymph flow, and lymphatic lipid and drug transport rates, comes from in vitro studies and in vivo animal studies. In contrast, intestinal lymphatic transport studies in human subjects have been limited. Recently, three surgical patients had cannulation of the thoracic lymph duct for collection of lymph before and during a stepwise increase in enteral feed rate. We compared these data to studies where we previously enterally administered controlled quantities of lipid and the lipophilic drug halofantrine to mice, rats and dogs and collected lymph and blood (plasma). The collected lymph was analyzed to compare lymph flow rate, triglyceride (TG) and drug transport rates, and plasma was analyzed for drug concentrations, as a function of enteral lipid dose across species. Lymph flow rate, TG and drug transport increased with lipid administration in all species tested, and scaled allometrically according to the equation A = aM E where A is the lymph transport parameter, M is animal body mass, a is constant and E is the allometric exponent. For lymph flow rate and TG transport, the allometric exponents were 0.84-0.94 and 0.80-0.96, respectively. Accordingly, weight normalized lymph flow and TG mass transport were generally lower in larger compared to smaller species. In comparison, mass transport of drug via lymph increased in a greater than proportional manner with species body mass with an exponent of ∼1.3. The supra-proportional increase in lymphatic drug transport with species body mass appeared to be due to increased partitioning of drug into lymph rather than blood following absorption. Overall, this study proposes that intestinal lymphatic flow, and lymphatic lipid and drug transport in humans is most similar to species with higher body mass such as dogs and underestimated by studies in rodents. Notably, lymph flow and lipid transport in humans can be predicted from animal data via allometric scaling suggesting the potential for similar relationships with drug transport.
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Affiliation(s)
- Natalie L Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Given Lee
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia.,Centre for Drug Candidate Optimisation, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Alistair Escott
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Kian Liun Phang
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Jiwon Hong
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - Enyuan Cao
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Kasiram Katneni
- Centre for Drug Candidate Optimisation, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Susan A Charman
- Centre for Drug Candidate Optimisation, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Sifei Han
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - William N Charman
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Anthony R J Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Christopher J H Porter
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
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7
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O'Hagan LA, Windsor JA, Phillips ARJ, Itkin M, Russell PS, Mirjalili SA. Anatomy of the lymphovenous valve of the thoracic duct in humans. J Anat 2020; 236:1146-1153. [PMID: 32103496 DOI: 10.1111/joa.13167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/08/2020] [Accepted: 01/20/2020] [Indexed: 12/15/2022] Open
Abstract
The majority of lymph generated in the body is returned to the blood circulation via the lymphovenous junction (LVJ) of the thoracic duct (TD). A lymphovenous valve (LVV) is thought to guard this junction by regulating the flow of lymph to the veins and preventing blood from entering the lymphatic system. Despite these important functions, the morphology and mechanism of this valve remains unclear. The aim of this study was to investigate the anatomy of the LVV of the TD. To do this, the TD and the great veins of the left side of the neck were harvested from 16 human cadavers. The LVJs from 12 cadavers were successfully identified and examined macroscopically, microscopically, and using microcomputed tomography. In many specimens, the TD branched before entering the veins. Thus, from 12 cadavers, 21 LVJs were examined. Valves were present at 71% of LVJs (15/21) and were absent in the remainder. The LVV, when present, was typically a bicuspid semilunar valve, although the relative size and position of its cusps were variable. Microscopically, the valve cusps comprised luminal extensions of endothelium with a thin core of collagenous extracellular matrix. This study clearly demonstrated the morphology of the human LVV. This valve may prevent blood from entering the lymphatic system, but its variability and frequent absence calls into question its utility. Further structural and functional studies are required to better define the role of the LVV in health and disease.
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Affiliation(s)
- Lomani Archibald O'Hagan
- Department of Anatomy and Medical Imaging, School of Medical Sciences, University of Auckland, Auckland, New Zealand.,Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
| | - John Albert Windsor
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Anthony Ronald John Phillips
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Maxim Itkin
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA, Pennsylvania
| | - Peter Spencer Russell
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Seyed Ali Mirjalili
- Department of Anatomy and Medical Imaging, School of Medical Sciences, University of Auckland, Auckland, New Zealand
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8
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Sarfarazi A, Lee G, Mirjalili SA, Phillips ARJ, Windsor JA, Trevaskis NL. Therapeutic delivery to the peritoneal lymphatics: Current understanding, potential treatment benefits and future prospects. Int J Pharm 2019; 567:118456. [PMID: 31238102 DOI: 10.1016/j.ijpharm.2019.118456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/21/2019] [Accepted: 06/21/2019] [Indexed: 12/20/2022]
Abstract
The interest in approaches to deliver therapeutics to the lymphatic system has increased in recent years as the lymphatics have been discovered to play an important role in a range of disease states such as cancer metastases, inflammatory and metabolic disease, and acute and critical illness. Therapeutic delivery to lymph has the potential to enhance treatment of these conditions. Currently much of the existing data explores therapeutic delivery to the lymphatic vessels and nodes that drain peripheral tissues and the intestine. Relatively little focus has been given to understanding the anatomy, function and therapeutic delivery to the peritoneal lymphatics. Gaining a better understanding of peritoneal lymphatic structure and function would contribute to the understanding of disease processes involving these lymphatics and facilitate the development of delivery systems to target therapeutics to the peritoneal lymphatics. This review explores the basic anatomy and ultrastructure of the peritoneal lymphatics system, the lymphatic drainage pathways from the peritoneum, and therapeutic and delivery system characteristics (size, lipophilicity and surface properties) that favour lymph uptake and retention after intraperitoneal delivery. Finally, techniques that can be used to quantify uptake into peritoneal lymph are outlined, providing a platform for future studies.
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Affiliation(s)
- Ali Sarfarazi
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Given Lee
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia
| | - S Ali Mirjalili
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony R J Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand; HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Natalie L Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia.
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Nomura T, Niwa T, Ozawa S, Oguma J, Shibukawa S, Imai Y. The Visibility of the Terminal Thoracic Duct Into the Venous System Using MR Thoracic Ductography with Balanced Turbo Field Echo Sequence. Acad Radiol 2019; 26:550-554. [PMID: 29748046 DOI: 10.1016/j.acra.2018.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 12/30/2022]
Abstract
RATIONALE AND OBJECTIVES Magnetic resonance thoracic ductography (MRTD) with balanced turbo field echo (bTFE) can visualize both the thoracic duct and its surrounding vessels. This study aimed to investigate the visibility of the terminal thoracic duct into the venous system in the subclavian region using MRTD with bTFE. MATERIALS AND METHODS MRTD was performed with bTFE as a preoperative workup comprising respiratory gating on a 1.5-T magnetic resonance system for patients with esophageal cancer. The portion and the number of terminal thoracic ducts into the venous system and preterminal branching in the left subclavian region were assessed using MRTD in 132 patients. The confidence level of the visibility using MRTD was also evaluated. RESULTS The most frequent terminal portion of the thoracic duct was the jugulovenous angle (92 patients, 69.7%), followed by the subclavian vein (27 patients, 20.5%) and the internal jugular vein (8 patients, 6.1%). Four patients also exhibited double entry of the thoracic duct into the venous system. The preterminal branching was single in 96 patients (72.7%) and multiple in 36 patients (27.3%). The confidence level of the visibility of the thoracic duct using MRTD was absolutely certain in 112 patients (84.8%) and was somewhat certain in 20 patients (15.2%). CONCLUSIONS MRTD with bTFE is a robust imaging modality to visualize the terminal portion of the thoracic duct into the venous system in the subclavian region.
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Affiliation(s)
- Takakiyo Nomura
- Department of Diagnostic Radiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
| | - Tetsu Niwa
- Department of Diagnostic Radiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan.
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Junya Oguma
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Shuhei Shibukawa
- Department of Radiology, Tokai University Hospital, Isehara, Japan
| | - Yutaka Imai
- Department of Diagnostic Radiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
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10
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Ratnayake CBB, Escott ABJ, Phillips ARJ, Windsor JA. The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: potential implications for intervention. J Anat 2018; 233:1-14. [PMID: 29635686 DOI: 10.1111/joa.12811] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 12/31/2022] Open
Abstract
The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108 years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.
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Affiliation(s)
| | | | - Anthony Ronald John Phillips
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, New Zealand
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11
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Itkin M, Nadolski GJ. Modern Techniques of Lymphangiography and Interventions: Current Status and Future Development. Cardiovasc Intervent Radiol 2017; 41:366-376. [PMID: 29256071 DOI: 10.1007/s00270-017-1863-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 12/14/2017] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Maxim Itkin
- HUP/CHOP Center for Lymphatic Imaging and Interventions, Penn Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Gregory J Nadolski
- HUP/CHOP Center for Lymphatic Imaging and Interventions, Penn Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Windsor JA, Escott A, Brown L, Phillips AR. Novel strategies for the treatment of acute pancreatitis based on the determinants of severity. J Gastroenterol Hepatol 2017; 32:1796-1803. [PMID: 28294403 DOI: 10.1111/jgh.13784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/04/2017] [Accepted: 03/05/2017] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis (AP) is a common disease for which a specific treatment remains elusive. The key determinants of the outcome from AP are persistent organ failure and infected pancreatic necrosis. The prevention and treatment of these determinants provides a framework for the development of specific treatment strategies. The gut-lymph concept provides a common mechanism for systemic inflammation and organ dysfunction. Acute and critical illness, including AP, is associated with intestinal ischemia and drastic changes in the composition of gut lymph, which bypasses the liver to drain into the systemic circulation immediately proximal to the major organ systems which fail. The external diversion of gut lymph and the targeting of treatments to counter the toxic elements in gut lymph offers novel approaches to the prevention and treatment of persistent organ failure. Infected pancreatic necrosis is increasingly treated with less invasive techniques, the mainstay of which is drainage, both endoscopic and percutaneous. Further improvements will occur with the strategies to accelerate liquefaction and through a fundamental re-design of drains, both of which will increase drainage efficacy. The determinants of severity and outcome in patients admitted with AP provide the basis for innovative treatment strategies. The priorities are to translate the gut-lymph concept to clinical practice and to improve the design and active use of drains for infected complications of AP.
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Affiliation(s)
- John A Windsor
- Pancreas Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Alistair Escott
- Pancreas Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Lisa Brown
- Pancreas Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony Rj Phillips
- Pancreas Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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