Duct Lymph Research Articles

277. SIMPLE METHOD: INGUINAL LYMPHANGIOGRAPHY FOR POSTOPERATIVE CHYLOTHORAX

Abstract Background Chylothorax is a well-known complication of esophageal cancer surgery, with an incidence of approximately 1–3%. The main cause is intraoperative damage to the thoracic duct, which is often discovered after postoperation. If conservative treatment is chosen, lymphangiography with Lipiodol is the diagnostic and embolization procedure for exposed areas. Itkin et al. reported that improvement rate is approximately 70%. Pedal lymphangiography has been used in the past, but we perform lymphangiography from the inguinal lymph node. Method We inject lipiodol under ultrasound guidance. A total of 6–10 mL injected into each bilateral inguinal lymph node. The lipiodol drain upstream from the main lumbar lymphatic trunk and contrasts into the thoracic duct under fluoroscopy. CT scans would be useful in the case that contrasts were unclear. Result If it is possible to inject lipiodol into the inguinal lymph nodes, even the thoracic ducts can be easily detected. With the classical method, an incision must be made between the first and second toes under local anesthesia, and minute lymph ducts must be identified and injected. However, if the inguinal lymph nodes are small, the drug tends to leak easily. Leakage is immediately detectable by fluoroscopy, so large leakage is unusual. If the drug is absorbed slowly, it remains subcutaneously after several months and can be identified as an artifact on abdominal X-rays or CT. Conclusion Lymphangiography from the inguinal lymph node is a relatively safe and simple method of examination, compared to the intervention from the dorsal foot. No skin incision on the dorsal foot is required, only an echo guided puncture is necessary. The examination time is short, and the patient burden is low. The procedure is not particularly difficult, so it can be performed even at small hospitals.

Impact of Positive-Margin Resection of External Auditory Canal Squamous Cell Carcinoma.

Positive-margin resection of external auditory canal squamous cell carcinoma (EAC-SCC) is still a major cause of recurrence. The aim of this study is to examine the clinical impact of positive-margin resection of EAC-SCCs. We retrospectively reviewed 40 surgical cases with en bloc temporal bone resection of EAC-SCC at a tertiary referral center from October 2016 to March 2022. Two-year disease-specific, overall, and disease-free survival rates for all 40 cases reviewed were 85.2%, 88.85%, and 76.96%, respectively. En bloc resection with a negative margin significantly improved patient prognosis (p < 0.001). Positive-margin resection was observed in 9/40 cases (22.5%). Insufficient assessment of preoperative images was the cause in two of these cases. Postoperative lymph node metastasis and distant metastasis were observed in cases in which vascular, lymphatic duct or perineural invasion was found on postoperative pathological examination. In addition, three cases in which no vascular, lymphatic duct, or perineural invasion was found exhibited local recurrence during the follow-up period. Of the nine positive-margin resection cases, only two showed no postoperative recurrence. Once positive-margin resections are confirmed, cases might have a high risk of tumor recurrence, even with the addition of postoperative adjuvant chemoradiotherapy.

SubQ-Sim: A Subcutaneous Physiologically Based Biopharmaceutics Model. Part 1: The Injection and System Parameters.

To construct a detailed mechanistic and physiologically based biopharmaceutics model capable of predicting 1) device-formulation-tissue interaction during the injection process and 2) binding, degradation, local distribution, diffusion, and drug absorption, following subcutaneous injection. This paper is part of a series and focusses on the first aspect. A mathematical model, SubQ-Sim, was developed incorporating the details of the various substructures within the subcutaneous environment together with the calculation of dynamic drug disposition towards the lymph ducts and venous capillaries. Literature was searched to derive key model parameters in healthy and diseased subjects. External factors such as body temperature, exercise, body position, food or stress provide a means to calculate the impact of "life events" on the pharmacokinetics of subcutaneously administered drugs. The model predicts the tissue backpressure time profile during the injection as a function of injection rate, volume injected, solution viscosity, and interstitial fluid viscosity. The shape of the depot and the concentrations of the formulation and proteins in the depot are described. The model enables prediction of formulation backflow following premature needle removal and the resulting formulation losses. Finally, the effect of disease (type 2 diabetes) or the presence of recombinant human hyaluronidase in the formulation on the injection pressure, are explored. This novel model can successfully predict tissue back pressure, depot dimensions, drug and protein concentration and formulation losses due to incorrect injection, which are all important starting conditions for predicting drug absorption from a subcutaneous dose. The next article will describe the absorption model and validation against clinical data.

Effect of Obesity on Lymphatic Fluid Filtration in Inguinal Lymph Nodes

Objective: The objective of this study was to investigate the potential impact of radionuclide imaging on filtration in the inguinal lymph nodes of obese patients. We aimed to compare the lymphatic transport after the inguinal lymph nodes between obese patients and normal-weight individuals, while ensuring intact lower extremity lymphatic flow. Methods: A retrospective study design was employed, involving the re-evaluation of patient images. Among the total of 119 patients, 62 were classified as obese, while the remaining patients had body mass indexes within normal limits. All patients included in the study were female, with a mean age of 39 years (ranging from 28 to 47 years). Lymphatic imaging was performed using Tc-99m-labeled nanocolloid particles with a size of 50-70 nm. The nanocolloid was applied to the 1st and 2nd interdigital web areas on the dorsum of both feet. Late images were captured at 45-50 minutes and 2 hours after application. Results: Out of the 119 patients, 62 (52%) were classified as obese. There was no significant difference in terms of age between the two groups. The pre-inguinal average count values, calculated from the counts before the inguinal node, did not show a significant difference between the two groups. However, the post-inguinal average count values obtained after the inguinal nodes were significantly lower in obese patients compared to normal-weight patients (p&lt;0.0005). Conclusion: Our findings suggest that even in the early stages, when functional imaging allows observation of the main lymphatic duct, there are differences in the progression of lymphatic flow between obese patients and normal-weight individuals. Detecting these differences may enable early diagnosis of lymphedema disease, which is a reversible disorder if identified promptly.

Jean Pecquet (1622–1674). To the 400th anniversary of the birth

The article is dedicated to the 400th anniversary of the birth of the outstanding French anatomist, physician and philosopher Jean Pecquet (1622–1674). Pecquet’s biography is connected with the city of Dieppe, where the future scientist was born and got his primary education, and with Paris, where he made his main discoveries in anatomy. Throughout his life, Pecquet collaborated with many prominent scientists of that time (Jacques Mentel, Louis Gayant, Jean Riolan (the Younger)), including not only physicians and anatomists, but also physicists such as Blaise Pascal, Edme Mariotte, Marin Mersenne and Evangelista Torricelli. Pecquet’s most famous discovery is the chyle cictern, or cisterna chyli. The structure was named after of the scientist – “Pecquet’s reservoir (cistern)”. But more revolutionary discovery made by Pecquet is revealing and proving the fact that the lymphatic ducts flow into the superior vena cava indirectly through the venous angles and refuting the conventional opinion on the drainage of lymph into the liver. An important help in Pecquet’s anatomical research and experiments was his passion for the physical and mathematical sciences. In collaboration with Edme Marriott, Pecquet studied the structure of the eyeball and turned out to be more foresighted, because, unlike Marriott, he correctly understood the role of the retina in the functioning of the eye as an organ of vision. Pecquet was one of William Harvey’s supporters regarding his concept of blood circulation. He introduced cutting-edge at that moment technologies into the anatomy methodology, including animal experiments in vivo, and made a fateful contribution to the progress of anatomical science.

The Deciding Factors of Flow Direction in Lymphovenous Anastomosis for Extremity Lymphedema.

While using lymphovenous anastomosis (LVA) to treat extremity lymphedema, an antegrade lymphatic-to-venous flow is usually considered to indicate a functional and effective anastomosis. The authors analyzed the characteristics of lymphovenous anastomoses in patients with extremity lymphedema to look for the deciding factors of the flow direction. A total of 45 patients (15 arms and 42 legs) undergoing LVA for extremity lymphedema were reviewed. Only the anastomoses with intraoperatively confirmed patent flow or clear visualization of vessel lumens during anastomosis were included for analysis. Multivariate logistic regression was used to identify the contributing factors of intraoperative washout phenomenon or venous reflux. A total of 105 eligible LVAs were included for analysis. Anastomosis with a more sclerotic lymphatic duct is statistically significantly associated with more venous reflux (OR, 2.82; P = 0.003). Larger diameter difference between lymphatic duct and recipient vein (OR, 12.8; P = 0.02) and less sclerotic lymphatic duct (OR, 0.47; P = 0.03) are statistically significantly associated with more washout phenomena. The deciding factors of flow direction in LVA are difference of diameters between lymphatic duct and recipient vein, and the severity of lymphosclerosis. To obtain favorable antegrade lymph-to-vein flow, a less sclerotic lymphatic duct with larger diameter and a recipient vein with smaller diameter should be chosen for anastomosis. Risk, III.

P277 MULTIFACTORIAL RECURRENT CHYLOUS ASCITES: THE CASE REPORT OF A PATIENT WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFPEF), LIVER DISEASE AND PAST ABDOMINAL SURGERY

Abstract Chylous ascites is the accumulation of triglyceride–rich fluid in abdominal cavity. It is caused by lymphatic ducts injury, usually as consequence of surgery, neoplasia, or infection. Rarely, it can also occur from heart failure, pericarditis, or cirrhosis. We report the case of a 66–year–old man electively hospitalized for acute renal failure and anasarca state. The cardiological history was significant due to acute myocardial infarction treated with CABG, PM implantation for complete AV block, atrial fibrillation, and type 2 diabetes mellitus. The entero–hepatological history started in 2019 when, two months after abdominal surgery for an incarcerated hernia, he developed chylous ascites and chylotorax. Starting from 2021, the patient presented recurrent episodes of tense ascites, requiring periodic paracentesis. Haematological and infectious disease evaluation resulted negative, liver biopsy showed congestive hepatopathy with fibrosis, while venous catheterization found high right filling pressure with not portal hypertension. Patient was treated with Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Metformin 1500 mg, Enalapril 20 mg, and Simvastatin 20 mg. During the hospitalization other paracentesis confirmed the chylous nature of the effusion, echocardiography (despite very bad acoustic windows) showed preserved left ventricle systolic function (LVEF 55%), 3rd degree LV diastolic disfunction, and dilatation of right ventricle, atria, and inferior Vena Cava. Right heart catheterization confirmed the presence of LV restrictive physiology, combined pulmonary hypertension, and ruled out the diagnosis of constrictive pericarditis. In hospital treatment focused on resolving acute renal failure and hypervolemia through intravenous diuretic and Albumin and on optimizing cardiological therapy. The patient was discharged with the following treatment: Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Canrenone 100 mg b.i.d., Empagliflozin 10 mg, Simvastatin 20 mg, and indication to hypo–lipidic diet. This case highlights how the coexistence of different predisposing factors of chylous ascites (past abdominal surgery, heart failure and liver disease) can amplify each other. Recognizing the single role of each of them is of pivotal importance to elaborate targeted treatment. Moreover, in literature, there are some cases of chylous ascites associated with constrictive pericarditis and with severe heart failure, but to our knowledge not with coexistence of HFpEF.

Chyloperitoneum signifying late bowel obstruction following gastric clipping with proximal jejunal bypass: A case report.

Chyloperitoneum (CP) is a rare complication after bariatric surgery. We present a 37-year-old female with CP caused by a bowel volvulus following a gastric clipping with proximal jejunal bypass for morbid obesity. An abdominal CT image of a mesenteric swirl sign and abnormal triglyceride level of ascites fluid can confirm the diagnosis. In this patient, laparoscopy demonstrated dilated lymphatic ducts caused by a bowel volvulus resulting in the exudation of chylous fluid into the peritoneal cavity. After the reduction of bowel volvulus, she made an uneventful recovery with complete resolution of the chylous ascites. The presence of CP could indicate a situation of small bowel obstruction in patients with a history of bariatric surgery.

HISTOLOGICAL AND MOLECULAR GENETIC CHARACTERISTICS OF CLINICALLY AGGRESSIVE VARIANTS OF PAPILLARY THYROID CARCINOMA: A LITERATURE REVIEW

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer; this cancer presents relatively low malignancy, good prognosis, and a 10-year survival rate of over 90 %. However, the clinical behaviors of this cancer are complex and varied. PTC is easy to spread via lymphatic ducts, which results in recurrence, metastases, and even death [1]. Differentiated thyroid cancer has a favorable prognosis in terms of relapsefree and overall survival. However, some cases of differentiated thyroid cancer (TC) are characterized by aggressive course with distant metastases. Identification of histological subtypes of papillary thyroid cancer (PTC) and detection of specific mutations may have some prognostic value in the prediction of the disease course and clinical response to treatment. The severity of the disease depends on multiple clinical characteristics, morphological and molecular features of the tumor. Several histological variants of PTC with varying degrees of malignancy have been described so far: from well-differentiated PTC to radioiodine refractory undifferentiated anaplastic carcinoma with a high mitotic index and high probability of relapses. Recurrent PTC mainly refers to localized and distant recurrence, including recurrence of the primary tumor, lymph node metastases, invasion of the esophagus and trachea, invasion of muscles, soft tissues and nerves, and distant metastases. Many factors can affect the recurrence of thyroid cancer, and final conclusion has not yet been reached. Aim: to summarize the available literature data on the molecular genetic characteristics of aggressive variants of papillary thyroid carcinoma. Methods: We conducted a literature review of scientific papers over the past decade using PubMed search engine resources. In addition, a search was conducted using the data of the scientific electronic library eLIBRARY for the above keywords. For this meta-analysis, we used articles containing clinical evidence on the most recent issues regarding aggressive variants of papillary thyroid carcinoma. Results: The highest frequency of BRAF V600E among PTC is shown by the high-cell variant of PTC (90%), also significantly higher with «shoe nail» cells than in classical PTC and varies from 40-90%. In a columnar cell, PTC, mutations in the BRAF V600E gene are much less common than in classic PTC. The diffuse sclerosing type of PTC is characterized by the presence of a RET/PTC translocation, and the percentage of the BRAF V600E mutation is 0-60 in various studies. Conclusion: In the presented work, the morphological and clinical features of patients with prognostic unfavorable variants of PTC are considered. Correct recognition of these variants is an important component in the diagnosis of tumor pathology of the thyroid gland, except for accidentally detected microcarcinomas without signs of invasion into the tissues and into the capsule of the thyroid gland and into the lymphatic vessels. The most aggressive forms of PTC include diffuse sclerosing, tall cell, and insular variants of PTC. Various genetic abnormalities, such as BRAF mutation, can be detected in this case. Thus, in some cases these markers can help to predict the course of TC and to provide adequate and timely treatment.

Increasing Linker Chain Length and Intestinal Stability Enhances Lymphatic Transport and Lymph Node Exposure of Triglyceride Mimetic Prodrugs of a Model Immunomodulator Mycophenolic Acid.

Targeted delivery of immunomodulators to the lymphatic system has the potential to enhance therapeutic efficacy by increasing colocalization of drugs with immune targets such as lymphocytes. A triglyceride (TG)-mimetic prodrug strategy has been recently shown to enhance the lymphatic delivery of a model immunomodulator, mycophenolic acid (MPA), via incorporation into the intestinal TG deacylation-reacylation and lymph lipoprotein transport pathways. In the current study, a series of structurally related TG prodrugs of MPA were examined to optimize structure-lymphatic transport relationships for lymph-directing lipid-mimetic prodrugs. MPA was conjugated to the sn-2 position of the glyceride backbone of the prodrugs using linkers of different chain length (5-21 carbons) and the effect of methyl substitutions at the alpha and/or beta carbons to the glyceride end of the linker was examined. Lymphatic transport was assessed in mesenteric lymph duct cannulated rats, and drug exposure in lymph nodes was examined following oral administration to mice. Prodrug stability in simulated intestinal digestive fluid was also evaluated. Prodrugs with straight chain linkers were relatively unstable in simulated intestinal fluid; however, co-administration of lipase inhibitors (JZL184 and orlistat) was able to reduce instability and increase lymphatic transport (2-fold for a prodrug with a 6-carbon spacer, i.e., MPA-C6-TG). Methyl substitutions to the chain resulted in similar trends in improving intestinal stability and lymphatic transport. Medium- to long-chain spacers (C12, C15) between MPA and the glyceride backbone were most effective in promoting lymphatic transport, consistent with increases in lipophilicity. In contrast, short-chain (C6-C10) linkers appeared to be too unstable in the intestine and insufficiently lipophilic to associate with lymph lipid transport pathways, while very long-chain (C18, C21) linkers were also not preferred, likely as a result of increases in molecular weight reducing solubility or permeability. In addition to more effectively promoting drug transport into mesenteric lymph, TG-mimetic prodrugs based on a C12 linker resulted in marked increases (>40 fold) in the exposure of MPA in the mesenteric lymph nodes in mice when compared to administration of MPA alone, suggesting that optimizing prodrug design has the potential to provide benefit in targeting and modulating immune cells.

Application of a Self-developed, Low-budget Indocyanine Green Camera in Surgical Imaging – a Single Institution’s Experiences

Introduction: Indocyanine green is a fluorescent dye, the use of which is becoming more and more widespread in different areas of surgery. Several international studies deal with the dye’s usefulness in intraoperative angiography, the localization of tumors, the more precise identification of anatomical structures, the detection of lymph nodes and lymph ducts, etc. The application of the dye is safe, but a suitable equipment park is required for its use, which entails relatively high costs.Objectives: The aim of our research is to create a detector system on a low budget, to be used safely in everyday practice and to illustrate its operation with practical examples at our own institute.Methods: By modifying a web camera, using filter lenses and special LEDs, we created a device suitable for exciting and detecting indocyanine green fluorescence. We prove its excellent versatility during the following procedures at our institute: breast tumor surgery, kidney transplantation, bowel resection, parathyroid surgery and liver tumor resection.Results: The finished camera has an LED light source with a peak wavelength of 780 nm, and the incoming light is filtered by a bandpass filter with a center wavelength of 832 nm. A low budget ($112), easy-to-use tool was created, which is suitable for taking advantage of the opportunities provided by indocyanine green.

Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome.

Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.

Intranodal dynamic contrast-enhanced CT lymphangiography and dynamic contrast-enhanced MR lymphangiography in microminipig.

To evaluate the feasibility and image quality of intranodal dynamic contrast-enhanced CT lymphangiography (DCCTL) and dynamic contrast-enhanced MR lymphangiography (DCMRL) in microminipigs. Our institution's committee for animal research and welfare provided approval. Three microminipigs underwent DCCTL and DCMRL after inguinal lymph node injection of 0.1mL/kg contrast media. Mean CT values on DCCTL and signal intensity (SI) on DCMRL were measured at the venous angle and thoracic duct (TD). The contrast enhancement index (CEI; increase in CT values pre- to post-contrast) and signal intensity ratio (SIR; SI of lymph divided by SI of muscle) were evaluated. The morphologic legibility, visibility, and continuity of lymphatics were qualitatively evaluated using a 4-point scale. Two microminipigs underwent DCCTL and DCMRL after lymphatic disruption and the detectability of lymphatic leakage was evaluated. The CEI peaked at 5-10min in all microminipigs. The SIR peaked at 2-4min in two microminipigs and at 4-10min in one microminipig. The peak CEI and SIR values were 235.6 HU and 4.8 for venous angle, 239.4 HU and 2.1 for upper TD, and 387.3 HU and 2.1 for middle TD. The visibility and continuity of upper-middle TD scores were 4.0 and 3.3-3.7 for DCCTL, and 4.0 and 4.0 for DCMRL. In the injured lymphatic model, both DCCTL and DCMRL demonstrated lymphatic leakage. DCCTL and DCMRL in a microminipig model enabled excellent visualization of central lymphatic ducts and lymphatic leakage, indicating the research and clinical potential of both modalities. • Intranodal dynamic contrast-enhanced computed tomography lymphangiography showed a contrast enhancement peak at 5-10min in all microminipigs. • Intranodal dynamic contrast-enhanced magnetic resonance lymphangiography showed a contrast enhancement peak at 2-4min in two microminipigs and at 4-10min in one microminipig. • Both intranodal dynamic contrast-enhanced computed tomography lymphangiography and dynamic contrast-enhanced magnetic resonance lymphangiography demonstrated the central lymphatic ducts and lymphatic leakage.

Development and application of a novel cervical lymph collection method to assess lymphatic transport in rats.

Background: Fluids, solutes and immune cells have been demonstrated to drain from the brain and surrounding structures to the cervical lymph vessels and nodes in the neck via meningeal lymphatics, nasal lymphatics and/or lymphatic vessels associated with cranial nerves. A method to cannulate the efferent cervical lymph duct for continuous cervical lymph fluid collection in rodents has not been described previously and would assist in evaluating the transport of molecules and immune cells from the head and brain via the lymphatics, as well as changes in lymphatic transport and lymph composition with different physiological challenges or diseases. Aim: To develop a novel method to cannulate and continuously collect lymph fluid from the cervical lymph duct in rats and to analyze the protein, lipid and immune cell composition of the collected cervical lymph fluid. Methods: Male Sprague-Dawley rats were cannulated at the carotid artery with or without cannulation or ligation at the cervical lymph duct. Samples of blood, whole lymph and isolated lipoprotein fractions of lymph were collected and analyzed for lipid and protein composition using commercial kits. Whole lymph samples were centrifuged and isolated pellets were stained and processed for flow cytometry analysis of CD3+, CD4+, CD8a+, CD45R+ (B220) and viable cell populations. Results: Flow rate, phospholipid, triglyceride, cholesterol ester, free cholesterol and protein concentrations in cervical lymph were 0.094 ± 0.014mL/h, 0.34 ± 0.10, 0.30 ± 0.04, 0.07 ± 0.02, 0.02 ± 0.01 and 16.78 ± 2.06mg/mL, respectively. Protein was mostly contained within the non-lipoprotein fraction but all lipoprotein types were also present. Flow cytometry analysis of cervical lymph showed that 67.1 ± 7.4% of cells were CD3+/CD4+ T lymphocytes, 5.8 ± 1.6% of cells were CD3+/CD8+ T lymphocytes, and 10.8 ± 4.6% of cells were CD3-/CD45R+ B lymphocytes. The remaining 16.3 ± 4.6% cells were CD3-/CD45- and identified as non-lymphocytes. Conclusion: Our novel cervical lymph cannulation method enables quantitative analysis of the lymphatic transport of immune cells and molecules in the cervical lymph of rats for the first time. This valuable tool will enable more detailed quantitative analysis of changes to cervical lymph composition and transport in health and disease, and could be a valuable resource for discovery of biomarkers or therapeutic targets in future studies.

Lymphatic System and Fistulas—Radiological Imaging Primer

While the imaging of arteries and veins by CT, MRI, and angiography is standard practice in large and small hospitals as well as in outpatient practices in developed countries, the diverse and sophisticated radiological procedures for imaging lymph ducts are often unknown and available only in a few specialized institutions [...]

Horner's Syndrome and Lymphocele Following Thyroid Surgery.

Horner’s syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid−related HS represents an unusual entity underling thyroid nodules/goiter/cancer−HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2−6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly <0.5%, except for a ratio of 8.3% in one study), correlates with extended surgery, especially lateral/central neck dissection, and the presence of congenitally—aberrant lymphatic duct; it is, also, described after endoscopic procedures and chest-breast approach; it starts within days after surgery. Typically low-fat diet (even fasting and parental nutrition) and tube drainage are useful (as part of conservative management); some used octreotide, local sealing solutions like hypertonic glucose, Viscum album extract, n-Butyl-2-cyanoacrylate. Re-intervention is required in severe cases due to the risk of lymphorrhoea and chylothorax. Early identification of Tx-HS and Tx-L improves the outcome. Some iatrogenic complications are inevitable and a multifactorial model of prediction is still required, also taking into consideration standardized operatory procedures, skillful intra-operatory manipulation, and close post-operatory follow-up of the patients, especially during modern era when thyroid surgery registered a massive progress allowing an early discharge of the patients.

Thoracoscopic diagnosis and clipping of an idiopathic defect of the thoracic lymphatic duct complicated by recurrent left-sided chylothorax

Thoracoscopic diagnosis and clipping of an idiopathic defect of the thoracic lymphatic duct complicated by recurrent left-sided chylothorax

Retroperitoneal laparoscopic partial adrenalectomy (RLPA) for 20-40mm nonfunctional adrenal tumors in the day surgery mode.

To investigate the outcome and safety of retroperitoneal laparoscopic partial adrenalectomy in the treatment of nonfunctional unilateral adrenal tumors in the day surgery mode. Nineteen patients bearing nonfunctional unilateral 20-40mm adrenal tumors were prospectively enrolled and underwent retroperitoneal laparoscopic partial adrenalectomy in the day surgery unit of our hospital between June 2021 and March 2022. All patients were diagnosed with non-functional adrenal tumors as outpatients before being admitted to the day surgery unit with their consent. Patient demographics and perioperative data were prospectively documented. The patients were followed up by telephone on day 1, 3 and 7 after discharge and followed up for 6 months. The patient's age was 50.5 ± 11.9 yr (range from 19.0 - 69.0). Seven patients were female. Twelve patients underwent surgery on the left side. The maximal diameter of tumor was 28.3 ± 5.7mm (20.0 - 40.0mm). Operation time was 72.1 ± 14.9min (58.0 - 120.0min). Mean blood loss was 64.7 ± 50.4ml (30.0 - 200.0ml). The gastrointestinal function recovery time was 9.7 ± 2.6h (6.0 - 16.0h). Retroperitoneal drainage was removed 24.8 ± 13.3h (range 18.0 - 72.0) after surgery. Four patients were transferred to the general ward for postoperative management, while others were discharged within 24 hours after surgery. Length of hospital stay was 48.8 ± 13.1h (38.0 - 85.0h). Hospitalization expense was 24168.4 ± 2910.3 RMB¥ (20844.3 - 34369.8 RMB¥). Postoperative pathology revealed 17 cortical adenoma, 1 pheochromocytoma and 1 lymphatic duct tumor. Retroperitoneal laparoscopic partial adrenalectomy for nonfunctional unilateral adrenal tumors in the day surgery mode is safe when strict selection criteria and perioperative management protocol are followed, which has the potential to shorten length of hospital stay and reduce lower hospitalization costs.

SURGICAL ASPECTS OF THE TREATMENT OF CHYLOTHORAX (CLINICAL OBSERVATIONS AND LITERATURE REVIEW)

Chylothorax is a rare disease that occurs due to damage to the thoracic lymphatic duct with the outflow of chyle from the lymphatic system into the pleural cavity, usually on the right.Establishing a final diagnosis for this disease is often associated with additional time costs, due to its relatively low prevalence. Currently, 65 scientific articles in Russian have been written on this topic.A necessary condition for the successful treatment of this disease is the identification of the root cause of its occurrence with its subsequent elimination.Despite the available scientific publications on this topic with a description of algorithmic approaches to diagnosis and treatment, sometimes, due to objective circumstances, it is necessary to correct these recommendations to ensure the most adequate treatment for a particular patient.

The Isolation of Flowing Mesenteric Lymph in Mice to Quantify In Vivo Kinetics of Dietary Lipid Absorption and Chylomicron Secretion.

Intestinal lipoproteins, especially triglyceride-rich chylomicrons, are a major driver of metabolism, inflammation, and cardiovascular diseases. However, isolating intestinal lipoproteins is very difficult in vivo because they are first secreted from the small intestine into the mesenteric lymphatics. Chylomicron-containing lymph then empties into the subclavian vein from the thoracic duct to deliver components of the meal to the heart, lungs, and, ultimately, whole-body circulation. Isolating naïve chylomicrons is impossible from blood since chylomicron triglyceride undergoes hydrolysis immediately upon interaction with lipoprotein lipase and other lipoprotein receptors in circulation. Therefore, the original 2-day lymph fistula procedure, described by Bollman et al. in rats, has historically been used to isolate fresh mesenteric lymph before its entry into the thoracic vein. That protocol has been improved upon and professionalized by the laboratory of Patrick Tso for the last 45 years, allowing for the analysis of these critical lipoproteins and secretions from the gut. The Tso lymph fistula procedure has now been updated and is presented here visually for the first time. This revised procedure is a single-day surgical technique for installing a duodenal feeding tube, cannulating the mesenteric lymph duct, and collecting lymph after a meal in conscious mice. The major benefits of these new techniques include the ability to reproducibly collect lymph from mice (which harnesses the power of genetic mouse models); the reduced anesthesia time for mice during the implantation of the duodenal infusion tube and the lymph cannula; the ability to continuously sample lymph throughout the feeding and post-prandial period; the ability to quantitatively measure hormones and cytokines before their dilution and enzymatic hydrolysis in blood; and the ability to collect large quantities of lymph for isolating intestinal lipoproteins. This technique is a powerful tool for directly and quantitatively measuring dietary nutrient absorption, intestinal lipoprotein synthesis, and chylomicron secretion.