The discovery of lymphatic system in the seventeenth century. Part I: the early history

The early history of lymphatic anatomy from Hippocrates (ca. 460–377 B.C.) to Eustachius (1510–1574). The presence of lymphatic vessels and lymph nodes was reported by ancient anatomists without any accurate knowledge of their true functions. Lymph nodes were described as spongy structures, spread over the whole body for the support of vulnerable body parts. Digestion was explained as being the resorption of clear chyle from digested food by the open endings of chyle vessels. The first insights into the place of lymphatic components within nutrition emanated from the medical school of Alexandria (fourth century B.C.) where vivisection was a common practice. Herophilus and Erasistratus described mesenteric veins full of clear liquid, air or milk. For Galen of Pergamum, (104–210) mesenteric lymph nodes also had a nutritional function. He described three different types of mesenteric vessels, namely, the arterial vessels, for the transport of spirituous blood to the intestines; the venous side branches of the portal vein, for the transport of nutritive blood from the liver to the intestines; and small vessels, from the intestines to the mesenteric lymph nodes (serous lymph vessels?). According to Galen, chyle was transported via the above-mentioned mesenteric venous vessels from the intestines to the portal vein and liver, where it was transformed into nutritive blood. This doctrine would be obliterated in the seventeenth century by the discovery of systemic circulation and of the drainage of chyle through a thoracic duct to the subclavian veins.     

The discovery of the lymphatic system in the seventeenth century. Part IV: the controversy

A controversy over the transport of chyle and lymph started a few weeks after the publication of Pecquet’s Experimenta Nova Anatomica. There are records of nearly seventy people who had an active interest in this matter. Three issues were discussed: the purpose of the liver and especially its haematopoietic function, the capacity of the thoracic duct to transport all chyle, and the purpose of the lymph vessels. The controversy over the use of the lacteals and the lymph vessels subsided about 20 years after the first publication of the new theories. In this contribution, we focused on the ideas of William Harvey, since his ideas were close to the real configuration of the lymphatic system, and on the peculiar anatomical set-up of Louis De Bils (ca 1624-1669), an obscure French-Flemish non-professional anatomist, who was the initiator of a heated controversy in the Netherlands with his original ideas.     

The discovery of the lymphatics in the seventeenth century. Part iii: the dethroning of the liver

Around 1650, the thoracic chyle duct and the serous lymph vessels were discovered nearly simultaneously in four different places on the European continent. The new theory was that all ingested fluid, digested food, and serous lymph liquid were drained towards the subclavian veins, and then to the heart where they was mixed with and transformed into blood, which had been the supposed function of the liver. None of the discoverers proposed a valuable alternative function for the liver. Bile formation and filtration of serum from the blood to carry it through lymph vessels to the chyle sac (cysterna chyli) were the only remaining possible liver functions. The liver was dethroned from its presumed function as blood-forming organ with an epitaph starting with the words ‘Stay, Wayfarer, Enclosed in this tomb is he who entombed very many’.     

Aetiology and treatment of chylous ascites.

A series of 45 patients with chylous ascites has been reviewed. The age at presentation ranged from 1 to 80 (median 12) years; 23 patients were aged < or = 15 years. Thirty-five patients had an abnormality of the lymphatics (primary chylous ascites); in the remaining ten, the ascites was secondary to other conditions, principally non-Hodgkin's lymphoma (six patients). Two principal mechanisms of ascites formation were identified using lymphangiography and inspection at laparotomy: leakage from retroperitoneal megalymphatics, usually through a visible lymphoperitoneal fistula (14 patients); and leakage from dilated subserosal lymphatics of the small intestine, invariably associated with leaking lacteals causing protein-losing enteropathy (24 patients). Both sites of leakage were present in a further five patients. In the remaining two patients, chyle was leaking from normal mesenteric lymphatics, in one via a ruptured mesenteric lymph cyst and in the other from the site of a previous lymph node biopsy. Other associated lymphatic abnormalities were present in 36 patients, lymphoedema of the leg being the commonest (26 patients). All patients were initially treated conservatively with dietary manipulation; this was the most satisfactory treatment for those with leaking small bowel lymphatics. Surgery (fistula closure, bowel resection or insertion of a peritoneovenous shunt) was performed in 30 patients. Closure of a retroperitoneal fistula, when present, was the most successful operation, curing seven of the 12 patients so treated.     

Mesenteric Chylothrombosis in Hyperlipidaemic Mink

In the familial form of hyperlipoproteinaemia type I of mink (Mustela vison), mesenteric lipogranulomas are common findings in longstanding cases. Patho‐morphological studies of early stages indicated that these lipogranulomas arose from stagnant chyle. The composition of fatty acids of a newly formed mesenteric granuloma was determined, together with fatty acids in liver, plasma and the feed. The results supported the pathological observations, as the fat of the granuloma differed from that of the liver and plasma, and contained only small amounts of the endogenous arachidonic acid, while the exogenous eicosenoic acid was present in amounts comparable with the dietary fat.     

Postoperative Chyle Leak After Major Pancreatic Resections in Patients Who Receive Enteral Feed: Risk Factors and Management Options

Background

Chyle leak complicates 1.3–10.8 % of pancreatic resections. Universal use of parenteral nutrition following pancreatic resection may reduce the incidence of chyle leak. However, this denies the majority of patients who do not develop chyle leak the benefits of enteral nutrition (EN). The present study aimed to identify risk factors for chyle leak following pancreatic resection within a single institution where EN was used universally.

Methods

All patients who underwent pancreatic resection between January 2007 and December 2010 were identified retrospectively. The patients had been treated according to a common unit protocol of enteral feeding; those developing chyle leak were switched to a medium-chain triglyceride (MCT) regimen. Clinical progress and recovery after surgery was evaluated. Multivariate analysis was performed to identify factors associated with chyle leak.

Results

A total of 245 patients underwent major pancreatic resection (231 pancreatoduodenectomy, 14 total pancreatectomy). Chyle leak complicated 40 cases (16.3 %). After multivariate analysis, both extensive lymphadenectomy (P = 0.002) and postoperative portal/mesenteric venous thrombosis (PVT) (P = 0.009) were independently linked with a higher incidence of chyle leak. The development of chyle leak was not associated with poorer survival or prolonged duration of hospital stay. It was associated with a significantly increased duration of abdominal drainage and reduced likelihood of early hospital discharge (P = 0.026).

Conclusions

Universal use of enteral feeding is associated with a high rate of chyle leak following pancreatic resection. Patients undergoing extensive lymphadenectomy or those who develop PVT postoperatively are at increased risk. Development of chyle leak was not associated with additional morbidity or mortality following implementation of an MCT regimen. The implication is that reactive management of chyle leak with conversion to a MCT predominant diet is safe.     

Congenital malformation of the lymphatics of the small intestine

Of 300 congenital malformations of the lymphatics of the small intestine investigated, 120 were operated upon. Intestinal lymphography shows no injection of the cisterna chyli and histology proves that the mesenteric lymph nodes are abnormal. The induced hyperlipidemia test permits a biochemical diagnosis. Modifications of the flow of the chyle secondary to the hypoplasia of the cisterna chyli were studied: (1) in the abdominal cavity, (2) in the extraperitoneal region and the lower limb, (3) in the thorax, especially the chyle drainage channels from the diaphragm towards the cervical region. Our investigations have established that the following diseases are produced by malformation of the lymphatics of the small intestine: protein losing enteropathy, chyloperitoneum, chyluria, lymphedema with chyle reflux, chylothorax, chylopericardium, chyle reflux in the pulmonary lymphatics, hypoproteinemia and food allergies. A better understanding of the pathophysiology of the malformations of the intestinal lymphatics permits a more rational treatment of the diseases produced by this anomaly.     

The Effects of Nitric Oxide Supplementation and Inhibition on Bacterial Translocation in Bile Duct Ligated Rats

Obstructive jaundice promotes bacterial translocation from the gut, but the role of nitric oxide is controversial in this process. We studied the effects of nitric oxide synthase substrate, L-arginine, and nitric oxide synthase inhibitor, NG-nitro-¿-arginine methyl ester, on bacterial translocation in bile duct ligated rats. The animals were randomized into five groups; control, sham, common bile duct ligation alone, nitric oxide inhibition, and nitric oxide supplementation. Obstructive jaundice was performed with common bile duct ligation. ¿-arginine or NG-nitro-¿-arginine methyl ester was injected once daily for 14 days. Blood bilirubin level, liver histology, and bacterial translocation to the mesenteric lymph nodes as well as to the liver were assessed. The ¿-arginine supplemented group had the lowest bacterial translocation rate, but the most prominent hepatic fibrosis. Nitric oxide inhibition increased bacterial translocation to the mesenteric lymph nodes. Therefore, the administration of nitric oxide donor or inhibitor acts as a significant regulatory factor for bacterial translocation in obstructive jaundice.     

Potential roles of the mesentery in Crohn's disease

The mesentery is the organ that supports development of all abdominal digestive organs in the foetus, and which supports and maintains all abdominal digestive organs in systemic continuity in the adult. Mesenteric abnormalities such as creeping fat are pathognomic of Crohn's disease and point to a pathobiological role for the mesentery. As part of the standard operative approach to resection, the mesentery is normally retained. Recent observations suggest that if the mesentery is included in the resections for ileocolic Crohn's disease, postoperative requirements for re-operation may be reduced. This is supported by emerging observations related to excision of the mesorectum during proctectomy for Crohn's disease, and by observations on the Kono-S procedure. As part of the latter, the mesentery is retained but is circumferentially excluded from the intestinal anastomosis. Mesenteric resection may also provide a more oncologically sound approach, in patients who also harbour a malignancy. Concerns regarding mesenteric resection relate to the possibility of mesenteric haemorrhage, and the lack of surgical planes in a hostile operative setting. Reliable haemostatic techniques have emerged that enable safe mesenteric division. Emerging data that support a staged approach to mesenteric resection, in complex operative settings. Increasing studies characterise the cellular and molecular basis of the net pathogenic effects of the mesentery. These could provide pharmacotherapeutic opportunities for the future avoidance of surgery. This article discusses the position of the mesentery in the pathobiology of Crohn's disease, and surgical strategies that alter mesenteric inputs.     

Preliminary experience with transluminal laser–induced intrahepatic portacaval shunts

This study investigated the feasibility of performing an intrahepatic portacaval shunt (IHPCS) by means of transluminal laser angioplasty. In 10 anesthized dogs, a catheter was introduced into a mesenteric vein and threaded into the portal vein (PV). Under fluoroscopy, a Ross needle was passed through the PV catheter, liver, and into the intrahepatic IVC. Following guidewire exchange, a neodymium YAG laser hot-tip probe (power setting 8 W) was passed over the guidewire to accomplish a transluminal IHPCS. In five animals, an IHPCS could not be accomplished. Initial and subsequent patency was confirmed by fluoroscopy. These early data suggest that transvenous laser-in-duced intrahepatic portacaval shunts may be feasible as a means of decompressing portal hypertension. Further research is necessary to investigate the long-term patency as well as this technique's ability to decompress the portal system. © 1993 Wiley-Liss, Inc.     

Definitive Surgical Treatment for Cholelithiasis in Selected Patients with Liver Cirrhosis

To determine whether definitive surgery such as cholecysectomy or extraction of bile duct stones is appropriate in cirrhotic patients the results of definitive surgery have been reviewed retrospectively in a group of 112 cirrhotic patients with cholelithiasis. Eighty-seven of these patients underwent definitive surgery for gallstones and the remaining 25 were treated conservatively.Child''s criteria were applied to each patient. Patients with Child''s grade A disease had fewer emergency procedures, operative blood loss and transfusion were less and they had a shorter hospital stay compared with patients with grades B and C. There were 4 deaths after definitive surgery for emergency conditions and these were all in Child''s grade C. Of the 83 survivors after definitive procedures .78 patients (93.9%) were still alive 52.8 months later without any biliary tract symptoms. Of the 25 patients undergoing conservative treatment 2 were Child''s B and 23 were Child''s C grade.We suggest that definitive surgery can be carried out safely, in Child''s A and B cirrhotic patients, either electively or as an emergency. However, a more conservative approach is advisable in Child C patients with acute conditions and definitive surgery is recommended as an elective procedure after the liver function has improved.     

Drainage Volume After Pancreaticoduodenectomy Is a Warning Sign of Chyle Leakage That Inversely Correlates With a Diagnosis of Pancreatic Fistula

Background

Chyle leakage is a rare complication of pancreaticoduodenectomy (PD), and its association with pancreatic fistula has not been established. The aim of this study was to (1) evaluate the incidence, management, and risk factors of chyle leakage after PD; (2) determine if there is a relation between chyle leakage and diagnosis of pancreatic fistula; and (3) predict chyle leakage with drainage volume early.

Methods

A total of 222 patients underwent PD or pylorus-preserving PD. We used the clinical database registry system of the Gangnam Severance Hospital, Yonsei University Health System to establish a retrospective cohort with clinicopathologic data.

Results

Altogether, 24 patients (10.8 %) developed chyle leakage. Chyle leakage was identified at a median 5 days after surgery and a mean 2 days after enteral intake. The mean drain triglyceride level was 315 mg/dl. Early enteral intake was independently associated with chyle leakage. Chyle leakage was inversely correlated with a diagnosis of pancreatic fistula with marginal significance (odds ratio 0.27; 95 % confidence interval 0.66–1.09). The receiver operating characteristic curve of the volume on postoperative day 4 demonstrated an area under the curve of 0.740 (p = 0.0001). Drainage >335 ml indicated possible chyle leakage.

Conclusions

Chyle leakage after PD is associated with early enteral intake. It was inversely correlated with a diagnosis of pancreatic fistula because of the dilution effect of drainage volume on the concentration of drained amylase. Because early diagnosis helps with appropriate management, prediction/suspicion of chyle leakage based on drainage volume may be useful.     

Massive per rectal bleeding following blunt abdominal trauma: First presentation of Crohn's disease

Introduction

Inflammatory bowel disease is a chronic and relatively common disorder with heterogeneous presentation. Peak incidence occurs in the second and third decades of life. We present a patient with Crohn''s disease whose first presentation was profuse bleeding/rectum following blunt abdominal trauma.

presentation of case

A 29 year old previously healthy man presented one hour after sustaining relatively mild abdominal trauma, due to fall onto the ball during a rugby match. He complained of abdominal pain and one episode of large fresh rectal bleeding. He was pale and distressed with hypotension, tachycardia and abdominal guarding & fresh blood on digital rectal examination. With a provisional diagnosis of intestinal injury he was taken to theatre. Right hemi-colectomy was done for a thickened and inflamed segment of distal ileum, a large adjacent mesenteric haematoma & mesenteric lymph nodes and blood in distal bowel. Histology confirmed the features of Crohn''s disease.

discussion

Crohn''s disease is unusual cause of massive lower gastrointestinal bleeding occurring in 0.9–6% of patients. Rectal bleeding associated with diarrhoea is relatively more common than massive bleeding. The presence of Crohn''s disease in young patients presenting like this is unlikely to be suspected and diagnosis could only be made after laparotomy.     

Chyle Leakage in Patients Undergoing Thyroidectomy Plus Central Neck Dissection for Differentiated Papillary Thyroid Carcinoma

Background  Chyle leakage is an uncommon complication of lateral neck dissection for metastatic papillary thyroid carcinoma (PTC). There have been no reports on chyle leakage after central neck dissection not combined with lateral neck dissection. We therefore investigated chyle leakage in PTC patients undergoing thyroidectomy and central neck dissection. Methods  A total of 283 new patients with differentiated PTC underwent total thyroidectomy plus central neck dissection. The amount and duration of drain leakage, and the concentrations of triglycerides and cholesterol in drain fluid and serum were measured in patients who had suspected postoperative chyle leakage. The incidence and management of chyle leakage were analyzed. Results  Intraoperative chyle leakage was not found in any patient, although postoperative leakage was detected in four patients (1.4%). Mean ± standard deviation peak 24-hour drainage was 122 ± 57 mL, and duration of leakage was 10 ± 7 days. Mean triglyceride concentration of drainage fluid was 433 ± 182 mg/dL. These patients were treated with pressure dressings and a medium-chain triglyceride diet. One patient underwent intralesional injection of OK-432 for localized chyle accumulation. All chyle leakages stopped after conservative management without surgical intervention. Conclusion  Chyle leakage can occur after thyroidectomy and central neck dissection not combined with lateral neck dissection. These findings will aid in the recognition and treatment of this uncommon complication during the early postoperative period.     

Acute Mesenteric Ischaemia—<Emphasis Type="Italic">An Indian Perspective</Emphasis>

In Western countries, acute mesenteric ischaemia is commonly due to arterial occlusion and occurs in patients who are usually in their seventh decade. A venous cause for intestinal gangrene has been reported in only about 10 %. We examined whether this was so in India and compared the clinical features of patients with mesenteric arterial and venous ischaemia and relate these to their ultimate prognosis. We studied retrospectively, the records of all patients admitted or referred to the department with a diagnosis of acute mesenteric ischaemia between January 1997 and October 2012, noting their demographic details and mode of presentation, the results of preoperative imaging and blood investigations, the extent of bowel ischaemia, and the length of bowel that was resected at operation and their outcome. There were 117 patients, 85 males and 32 females whose median age was 53 years. Mesenteric venous thrombosis was seen in 56 patients (48 %) and mesenteric arterial occlusion in 61 (52 %). Forty six patients died (39 %); 15 with venous occlusion (27 %) and 31 with arterial occlusion (51 %). Compared to patients with arterial occlusion, the patients with venous obstruction were younger, had a longer duration of symptoms, were less frequently hypotensive at presentation, had higher platelet counts, had a shorter length of bowel resected, had fewer colonic resections and had a lower mortality. Other predictors of mortality on multivariate analysis were a longer duration of symptoms, lower serum albumin and higher creatinine levels at presentation and a shorter length of residual bowel. In India, acute mesenteric ischaemia in tertiary care centres is due to venous thrombosis in almost half of the patients who are at least a decade younger than those in the West. Significant predictors of mortality include low serum albumin and raised creatinine levels, a shorter residual bowel length and an arterial cause for mesenteric ischaemia.     

Significance of selective arteriographic patterns in the celiac axis and superior mesenteric artery in portal hypertension

Selective celiac and superior mesenteric arteriographies were performed in patients with portal hypertension. An arterioarterial (A-A) shunt between the superior mesenteric artery and the celiac axis via pancreatic arcades was found in fifteen of forty-three patients with associated massive splenomegaly. A mild A-A shunt disappeared after portacaval anastomosis alone, whereas a prominent A-A shunt was reduced but persisted. The persisting A-A shunt disappeared after splenectomy. These findings led us to suggest that the paucity of the blood flow in the common hepatic artery concomitant with increased splenic arterial flow to the massively enlarged spleen may result in a compensatory supply to the liver from the superior mesenteric artery via the shunt.     

肠系膜动脉瘤破裂出血的诊治分析：附8例报告

背景与目的 肠系膜动脉瘤是一种罕见的疾病,大部分患者确诊时动脉瘤已出现破裂大出血,病情危重,治疗风险大。本文回顾性分析肠系膜动脉瘤破裂患者的病例特点,探讨该疾病诊断和治疗方式的选择。方法 回顾性分析于2016年1月—2020年12月在湖南省郴州市第一人民医院血管外科收治的8例肠系膜动脉瘤破裂出血患者的临床资料和随访情况。结果 8例患者行腹部CTA或腹部增强CT明确诊断为肠系膜动脉瘤破裂出血。患者均行急诊手术治疗,其中6例行腹腔动脉造影+栓塞术;1例因腔内治疗失败后选择行开放手术;1例首选开放手术。8例患者均抢救成功,3例患者腔内治疗术后出现腹痛腹胀,药物保守治疗好转;1例患者开放手术术后出现创伤性胰腺炎,予以药物治疗治愈。所有患者住院期间均无再出血、肠缺血、肠坏死等并发症与再次手术。8例患者均随访12个月,患者正常饮食后无腹痛腹胀不适,无再次出血;复查腹部增强CT或CTA提示动脉瘤栓塞良好,血肿明显吸收。结论 临床医生要提高对肠系膜动脉瘤破裂出血疾病的认识和警惕,及时做出正确诊断。手术治疗方案可分为开放手术和腔内治疗,均安全和有效,术前应根据患者病情、瘤体位置和形态决定具体手术方案。     

Liver transplantation in a patient with Budd-Chiari syndrome secondary to factor V Leiden mutation

A point mutation in the factor V Leiden gene is the most common hereditary thrombophilic state and an important risk factor for Budd-Chiari syndrome. We report on a patient with Budd-Chiari syndrome secondary to factor V Leiden mutation, who underwent successful liver transplantation. Following liver transplantation, his thrombophilic state was corrected and he did not require anticoagulation therapy. There has been no recurrent venous thrombosis for 14 months after transplantation. Although his activated protein C sensitivity was normal, showing the normalization of protein C–factor V interaction, PCR analysis demonstrated that heterozygosity for factor V Leiden mutation was still present.We suggest checking resistance to activated protein C, rather than PCR analysis of factor V Leiden mutation in patients with Budd-Chiari syndrome after liver transplantation; the presence of the second does not effect clinical outcome.     

Epidemiological study of farmer''s lung in five districts of the French Doubs province.

The prevalence of farmer''s lung was studied in five districts of the French Doubs province (Rougemont, Clerval, Levier, Montbenoît, Mouthe) on the basis of a medical and occupational questionnaire and serological studies for precipitins. Of the 1763 active farmers (response rate 69%) who participated in the study, 270 were suspected of having farmer''s lung and divided, on the basis of clinical and serological criteria, into probable and possible farmer''s lung groups. This subgroup of 270 patients was examined in more detail with physical examination, chest radiographs, and pulmonary function tests. Probable farmer''s lung was diagnosed in 77 cases (53 men and 24 women, mean age 51.7 years), a prevalence of 43.7/1000. Possible farmer''s lung was present in a further 193 subjects. Fever was the most specific symptom. In the group with probable farmer''s lung the frequency of crepitations, restrictive ventilatory defect, and radiological interstitial abnormalities was 21.5%, 9.5%, and 9.2% at the time of the study. Farmer''s lung was more common in the middle tablelands than in the plain or mountain areas (p less than 0.01). The difference in prevalence of farmer''s lung between the Mouthe mountain and Levier middle tableland districts (25.2/1000 and 60.8/1000) raises the possibility that cold may protect against the disease. Farmer''s lung was more frequent in men and in the age group 51-55 years. Among possible occupational factors, only regular work connected with feeding animals was associated with a significant risk (odds ratio 2.55 with a 95% confidence interval of 1.09-5.93). The frequency of chronic bronchitis in the population studied was 14.8%. There was a close link between farmer''s lung and chronic bronchitis, 50.6% of patients with probable farmer''s lung having it but only 8.6% of patients without farmer''s lung (p less than 0.001). In patients with probable farmer''s lung chronic bronchitis was independent of smoking and age. There were fewer smokers in the probable farmer''s lung than in the non-farmer''s lung group (p less than 0.05).     

多学科交叉背景下中医手法治疗颈椎病效应机制研究现状与思考

中医手法效应机制研究是目前手法研究中的关键科学问题, 是中医骨伤科现代化与国际化道路上的重点和难点。现阶段,我国正逢多学科交叉引领知识生产、科技创新、学科发展的重要时期,中医骨伤学科与其他学科交叉创新的发展趋势为推动中医手法效应机制研究提供了载体。颈椎病作为中医骨伤学科的优势病种,近年来许多学者基于多学科的技术和理论开展中医手法效应机制研究。本文以中医手法治疗颈椎病为切入点,重点围绕颈部肌群,颈椎椎体、椎间盘、椎体附件,颈部血管,神经系统 4 个维度,整合了多学科交叉背景下中医手法效应机制研究中多种技术和理论的应用现状和实施策略,有利于中医骨伤学科与其他学科更好地结合、创新、转化,为系统阐明手法的科学内涵提供思路与借鉴。