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The authors studied the terminal portion in fifteen newborn thoracic ducts, using the neoprene latex injection method and posterior dissection. Variations in the manner and number of terminations of the thoracic ducts were found and described. The results are compared with data from the literature. Differences between newborns and adults are discussed.
BACKGROUND: Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy. METHODS: We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis. RESULTS: There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation. CONCLUSIONS: Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.
The localization of Von Willebrand factor-like immunoreactivity (VWFI) in the thoracic duct endothelium was investigated by means of preembedding immunoelectron microscopy. In the endothelial cells, VWFI was observed within rod-shaped Weibel-Palade bodies (WPBs) with an occasional tadpole-like appearance. The WPBs occasionally appeared to be associated with Golgi complexes of the endothelial cells. Some cisternae of the rough endoplasmic reticulum located in the perikarya of the endothelial cells also exhibited VWFI. There was a small number of large VWFI vesicles in the periphery of the endothelial cells. These findings provide morphological evidence for the thoracic duct as a site of VWF synthesis and suggest further that VWF is produced in the rough endoplasmic reticulum and transported into the WPBs and large vesicles occasionally via the Golgi apparatus.
The authors studied the development of collateral circulation between the thoracic duct and the azygous vein system, in 30 adult dogs, after thoracic duct ligature. They verified the existence of lymphatico-venous communications in 18 events (60%); in 10 of these cases and in the rest (40%) alterations related to the duct's morphology were found; these alterations are not usually evident or inexist in animals not submitted to duct ligature.
The postion of the thoracic duct and its relationship to the spine was examined during the course of 100 autopsies on subjects aged 48 to 95 years. Four variants in its position and two variants in shape were found, with a percentage incidence of left-sided 36%, mid-line 20%, oblique 17%, rightsided 6%, bowed 14%, angulated 7M. The midline, oblique and right-sided positions are variants related to age or consitution, left-sided postion is regarded as related to age. The variations in shape are regarded as pathological changes due to displacement of the aorta.
The effect of continuous removal of thoracic duct lymph on plasma activities of creatine phosphokinase (PCK), glutamic-oxaloacetic transaminase (PAST); and lactic dehydrogenase (PLDH), uas examined in pentobarbital-anaesthetised dogs over a 5.5-hour period. PCK and PAST declined relative to levels in control dogs while PLDH was unaltered. Lymph/plasma (L/P) ratios for AST and CPK were greater, and for LDH less, than the L/P ratio for total protein. It was concluded that PCK, and to some extent PAST, are normally maintained by introduction of enzyme, escaping from the intracellular compartment, into the circulating blood via the lymphatic system. PLDH and PAST appear to be maintained principally by introduction of enzyme directly from the intracellular to the plasma compartment.
Thoracic duct lymphocytes (TDL) from C3H/Tif and BALB/c mice were studied for their in vitro reactivity to the B cell mitogens lipopolysaccharide (LPS) and lipoprotein (LP). Roughly 4% and 10% of the surface immunoglobulin (Ig)-positive cells in these populations could be stimulated by LPS and LP, respectively, to generate clones of IgM-secreting cells. Among LPS-reactive B cells, roughly 30% developed into clones which also produced IgG3 or IgG2, while only a very small fraction (1-2%) of all precursors could give rise to clones secreting IgG1 and IgA. Freshly collected TDL from some batches of C3H/HeJ mice displayed a high proportion of Ig-containing B cell blasts (5-10%), which did not secrete enough Ig to be detected as plaque-forming cells (PFC). These cells, however, under appropriate culture conditions and stimulated by LP (but not by Nocardia mitogen), differentiated to PFC of the various Ig classes without dividing.
OBJECTIVE: The purpose of this study was to evaluate the extent to which increased lymph flow can return fluid and protein to the circulation in the chronically anemic fetus. STUDY DESIGN: Thoracic duct lymph flow rate over a range of outflow pressures was measured in 8 near-term fetal sheep 4 to 5 days after surgery and daily thereafter for 5 days. After each day's study 60 to 150 ml of blood was withdrawn at a rate of 1 ml per minute. Regression analysis was used to establish the lymph flow function curve. Lymph and plasma protein concentrations and lymph flow rate were compared by analysis of variance for repeated measures. RESULTS: As the hematocrit was reduced from 34.6% +/- 1.3% (mean +/- SE) to 14.4% +/- 1.0%, thoracic duct lymph flow increased from 0.12 +/- 0.01 to 0.28 +/- 0.02 ml/min/kg. Plasma total protein concentration did not change, lymph protein concentration fell (2.6 +/- 0.1 to 2.4 +/- 0.1 gm/dl), and the difference between plasma and lymph protein concentrations increased (1.04 +/- 0.05 to 1.34 +/- 0.10 gm/dl). Protein returned to the circulation increased from 11.5 +/- 0.3 to 23.7 +/- 1.5 mg per minute. Central venous pressure did not change and remained less than the breakpoint pressure. Although the plateau lymph flow rate increased, neither the breakpoint or stopflow pressures of the lymph flow function curve were altered. CONCLUSIONS: Fetal lymph flow and thereby capillary filtration increased progressively as anemia became more severe. The increase in lymph flow did not appear to be limited by outflow pressure. By returning protein to the circulation, an increase in thoracic duct lymph flow helped to limit expansion of extravascular fluid volume during chronic fetal anemia.
Thoracic duct drainage has so far been employed in clinical nephrology mainly in renal transplantation and in immunologically mediated glomerulonephritis. The effectiveness of duct drainage in producing immunosuppression has been widely demonstrated, and several authors have used long-term, and others short-term drainage. 12 patients suffering from drug resistant immunologically mediated glomerulonephritis were treated with short-term (mean 10 days) thoracic duct drainage. In order to define the time, type and evolution of changes in immunological status, humoral and cellular immunity were studied daily in all patients. Marked changes (mainly in the number of lymphocytes drained and in their nucleic acid content and E-rosette forming capacity) take place in the first (4-5) days of drainage. These findings, together with positive clinical and laboratory results obtained in our patients, suggest that satisfactory immunosuppression may be achieved by short-term drainage, which is simpler and safer than long-term drainage. The procedure might thus be extended to a wider number of immunological diseases where drug therapy fails to take effect.
A marked rise is seen in the number of white blood cells in the lymph leaving the sheep kidney after allografting; the number of lymphocytes leaving the kidney rising in direct relation to the degree of damage from acute rejection. No such rise is demonstrable in the number of lymphocytes in the thoracic duct lymph of sheep with rejecting kidney allografts. Indeed, there is an apparent decrease in the number of lymphocytes in the thoracic duct lymph of sheep with rejecting kidney allografts. Indeed, there is an apparent decrease in the number of circulating lymphocytes in the body when acute rejection is fully developed. Animals on immunosuppressive regimens show no alteration in the number of lymphocytes collected on thoracic duct cannulation, but immunosuppression appears to reduce the lymphocyte traffic through the kidney.
The authors performed the ligature and transection of the thoracic duct in 36 dogs, 14 male and 22 female in order to investigate the existence of lymphatico-venous communications between the thoracic duct and veins situated in thorax, especially visceral veins. The animals were divided in 6 groups (5 experimental and 1 control), and were studied 30, 60, 90, 120, 150 and 180 days after the ligature. The existence of lymphatico-venous communications was observed in 18 cases (60%): 34.1% in esophageal veins; 34.1% in intercostal veins; 22.7% in azygous vein and 9.1% in the proper vein of the longus colli. The communications between the duct and the intercostal veins were more frequent in the veins from the left antimere; as for the azygous, the communications were more frequent in the segment between the 6th and 7th intercostal veins. No communications were observed in the control animals.
We studied the effect of lowering the plasma protein concentration on the cardiovascular function and thoracic duct lymph in awake adult sheep. Hypoproteinemia was induced in seven nonpregnant, splenectomized sheep by drainage of the thoracic duct lymph over a 5-day period. The plasma protein went from a mean of 6.4 +/- 0.2 (SE) to 4.9 +/- 0.2 g/dl on day 5, and the lymph-to-plasma protein concentration ratio decreased from 0.74 +/- 0.01 on day 1 to 0.48 +/- 0.04 on day 5. The percentage composition of the protein fractions in plasma and lymph remained unchanged. Lymph flow was 1.79 +/- 0.37 and 1.28 +/- 0.10 ml/min for days 1 and 5, respectively. Renin concentration in plasma increased 50-fold by day 5. Arterial pressure fell from 102.9 +/- 5.4 to 72.7 +/- 4.4 mmHg by day 5. Mean hematocrit was 28.9 +/- 1.7 at day 1, which was not significantly different than 24.6 +/- 2.9 at day 5 and indicated that the plasma volume did not decrease. Body weight also did not change significantly. There was a decrease in the transcapillary protein escape rate, determined as the thoracic lymph flow rate multiplied the lymph protein concentration, that suggests adaptations in the microcirculation to decrease vascular-to-interstitial protein transfer during hypoproteinemia. Hypoproteinemic animals also demonstrated greater vascular retention of a fluid volume challenge. In conclusion, the sheep adaptations to sustained hypoproteinemia produced by lymph drainage were a significant decrease in arterial pressure, large increases in vascular compliance and renin concentration, and reduced transcapillary escape rate of protein.(ABSTRACT TRUNCATED AT 250 WORDS)
In animal experiments the effect of lymph drainage from the thoracic duct on acute pancreatitis was studied. Experimental animals were dogs. Drainage was performed by inserting a catheter into the thoracic duct. Compared with control animals without drainage, values of amylase and lipase in blood, urine, and peritoneal exudate were lowered, the enzyme activity in lymph was elevated. The dogs with drainage survived for a longer time, the macroscopic and microscopic changes of the pancreas were less expressed.
Previous studies suggest that systemic endotoxemia in peritonitis is mainly related to lymphatic transport via the thoracic duct. Rats with fecal peritonitis but with or without a lymph draining thoracic duct fistula were studied with reference to the concentrations of endogenously produced endotoxin in arterial plasma, hemodynamic parameters, organ blood flow, blood corpuscle parameters, glucose and lactate metabolism and survival. Lymph drainage significantly reduced the endotoxin concentrations in arterial plasma, but did not totally prevent systemic endotoxemia, and was related to maintained total peripheral vascular resistance. On the other hand, peritonitic rats without lymph drainage, and consequently higher endotoxin concentrations, had a significant fall in vascular resistance combined with a compensatory rise in cardiac output. Lymph drainage also contributed to a smaller decrease of platelet and leucocyte counts while no effect was observed on glucose metabolism. Despite the effect of lymph drainage on hemodynamic and hematologic responses no effect on survival time was recorded.
The objectives of this study were to evaluate the physiological importance of the flow and shear generated by phasic contractions of lymphatic vessels and the mechanisms responsible for the influences of such shear on lymphatic pumping. Lymphatic segments of the rat thoracic duct were isolated, cannulated and pressurized. The diastolic diameters were measured in phasically non-active segments. The diastolic and systolic diameters, half-relaxation time (HRT), contraction frequency, ejection fraction and fractional pump flow were determined in phasically active segments. Since imposed flow was excluded, flow and shear occurred only as a result of the intrinsic contractions in phasically active segments whereas in phasically non-active segments contraction-generated flow and shear were absent. The influences of incrementally increased transmural pressure (from 1 to 5 cmH(2)O) were examined in control conditions and after NO synthase blockade (l-NAME 10(-4) m) or cyclooxygenase blockade (indomethacin 10(-5) m). The spontaneous phasic contractions produced a flow-dependent diastolic relaxation. This reduction of the lymphatic tone is a regulatory mechanism that maintains pumping in thoracic duct in an energy-saving/efficient mode: it improves diastolic filling (enhanced lusitropy - lowering HRT), makes lymphatic contractions stronger (enhanced inotropy - higher contraction amplitude) and propels more fluid forward during each contraction (elevated ejection fraction) while decreasing contraction frequency (reduced chronotropy). The findings also demonstrated that the NO pathway, not the cyclooxygenase pathway is responsible for this reduction of lymphatic tone and is the prevailing pathway responsible for the self-regulatory adjustment of thoracic duct pumping to changes in lymph flow pattern.
Nine patients with various types of severe glomerulonephritis were treated with drainage of the thoracic duct (n=8) and/or plasmapheresis (n=6) without the use of pharmacological immunosuppression. In most of the patients treatment produced a prompt temporary regression of albuminuria and creatininemia. In one patient renal function was substantially improved 8 months after the last period of treatment, in 2 patients the progress of the uremia was probably retarded. In the remaining 6 patients treatment had no obvious effect on the course of the illness. Drainage of the thoracic duct and plasmapheresis may be of benefit in the treatment of glomerulonephritis, but their proper utilization requires further studies.
The macroscopic arrangement of the termination of the thoracic duct (TD) was examined in detail in Japanese cadavers, and the distribution of various types of collagen, tenascin, laminin, and fibronectin in the framework of the wall of the thoracic duct termination was demonstrated. We identified several branching patterns and pathways of the TD (i.e., those terminating 1) at the venous angle (Type A); 2) at the end of the internal jugular vein (Type B); 3) at the the external jugular vein (Type C); or 4) in a complex with various branches (Type D). The TD often divided into two or three trunks before or after passing beneath the left brachiocephalic vein. Compared with the main trunk of the TD, fewer muscle fibers, elastic fibers, specific compounds of the extracellular matrices, and valvular connective tissues were found near the termination of the TD and the valves of the TD and veins. Smooth muscle cells were arranged irregularly in each region of the TD.
From the right superior mediastinum of a 31-year old woman the authors extirpated a lymphangiomyoma originating from the thoracic duct. The clinical feature and pathology of this rare lesions are discussed. This case is the first successfully removed thoracic duct lymphangiomyoma in Hungary.