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World Journal of Gastrointestinal... Dec 2021Crohn's disease (CD) is a complex and relapsing gastrointestinal disease with mesenteric alterations. The mesenteric neural, vascular, and endocrine systems actively... (Review)
Review
Crohn's disease (CD) is a complex and relapsing gastrointestinal disease with mesenteric alterations. The mesenteric neural, vascular, and endocrine systems actively take part in the gut dysbiosis-adaptive immunity-mesentery-body axis, and this axis has been proven to be bidirectional. The abnormalities of morphology and function of the mesenteric component are associated with intestinal inflammation and disease progress of CD responses to afferent signals, neuropeptides, lymphatic drainage, adipokines, and functional cytokines. The hypertrophy of mesenteric adipose tissue plays important roles in the pathogenesis of CD by secreting large amounts of adipokines and representing a rich source of proinflammatory or profibrotic cytokines. The vascular alteration, including angiogenesis and lymphangiogenesis, is concomitant in the disease course of CD. Of note, the enlarged and obstructed lymphatic vessels, which have been described in CD patients, are likely related to the early onset submucosa edema and being a cause of CD. The function of mesenteric lymphatics is influenced by endocrine of mesenteric nerves and adipocytes. Meanwhile, the structure of the mesenteric lymphatic vessels in hypertrophic mesenteric adipose tissue is mispatterned and ruptured, which can lead to lymph leakage. Leaky lymph factors can in turn stimulate adipose tissue to proliferate and effectively elicit an immune response. The identification of the role of mesentery and the crosstalk between mesenteric tissues in intestinal inflammation may shed light on understanding the underlying mechanism of CD and help explore new therapeutic targets.
PubMed: 35070062
DOI: 10.4240/wjgs.v13.i12.1536 -
Plastic and Reconstructive Surgery.... Apr 2022Surgical invasion of the lymphatic system can lead to lymphorrhea. Lymphorrhea is first treated conservatively, but is often refractory and subsequently treated...
Surgical invasion of the lymphatic system can lead to lymphorrhea. Lymphorrhea is first treated conservatively, but is often refractory and subsequently treated surgically. In surgery, it is difficult to identify the lymphatic leak points visually. In this study, we observed the schlieren phenomenon based on the difference in the refractive index between glucose solution and lymph fluid, and were able to easily identify the site of the lymphatic leakage in real time and treat lymphorrhea.
PubMed: 35450265
DOI: 10.1097/GOX.0000000000004269 -
Interventional Radiology... Nov 2021Intranodal embolization using n-butyl cyanoacrylate glue is an emerging treatment option for persistent lymphatic leakage. This report describes the procedure details of...
PURPOSE
Intranodal embolization using n-butyl cyanoacrylate glue is an emerging treatment option for persistent lymphatic leakage. This report describes the procedure details of intranodal embolization for groin lymphocele and evaluates the efficacy of intranodal embolization at our institution via retrospective chart review.
MATERIAL AND METHODS
Nine consecutive patients (six men and three women; median age, 77.4 years; range, 43-95 years) who underwent intranodal embolization for groin lymphocele between January 2017 and December 2019 were included as study subjects. Intranodal lymphangiography with iodinated contrast was performed to confirm lymphatic leakage, followed by intranodal embolization using n-butyl cyanoacrylate glue mixed with iodized oil for all nine patients. The etiologies of lymphocele, technical and clinical success rates of intranodal embolization, duration of treatment, follow-up period, and acute and chronic complications were retrospectively investigated.
RESULTS
The etiologies of groin lymphoceles were the cutdown access of inguinal vessels (n = 7), lymph node biopsy (n = 1), and trauma (n = 1). The technical and clinical success rates of both lymphangiography and subsequent intranodal embolization were 100%. For intranodal embolization, 16.7%-33.3% n-butyl cyanoacrylate glue was used. The median duration of treatment was 2 days (range, 1-13 days). The follow-up period lasted 0-895 days (median, 9 days). No acute or chronic complications were observed.
CONCLUSIONS
In this study, intranodal embolization showed promising results for groin lymphocele with a short duration of treatment with a median of 2 days. Intranodal embolization using n-butyl cyanoacrylate glue could be a treatment option for persistent groin lymphocele. However, further research is warranted to further evaluate the efficacy of intranodal embolization.
PubMed: 35912276
DOI: 10.22575/interventionalradiology.2020-0034 -
Current Opinion in Urology Jul 2023Although lymph node dissection (LND) during radical nephroureterectomy (RNU) is recommended for high-risk nonmetastatic upper tract urothelial carcinoma (UTUC),... (Review)
Review
PURPOSE OF REVIEW
Although lymph node dissection (LND) during radical nephroureterectomy (RNU) is recommended for high-risk nonmetastatic upper tract urothelial carcinoma (UTUC), adherence to guidelines remains insufficient in clinical practice. Therefore, this review aims to comprehensively summarize the current evidence regarding the diagnostic, prognostic, and therapeutic impact of LND during RNU in UTUC patients.
RECENT FINDINGS
Clinical nodal staging using conventional CT scan has low sensitivity (25%) and diagnostic accuracy [area under the curve (AUC): 0.58] in UTUC, suggesting the importance of LND for obtaining accurate N-staging. Patients with pathological node-positive (pN+) disease have poor disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) compared with those with pN0. In addition, population-based studies showed that patients who underwent LND improved CSS and OS than those who did not, even in patients who received adjuvant systemic therapy. The number of lymph nodes removed has also been shown to be associated with improved CSS and OS, even in pT0 patients. Template-based LND should be performed as the extent of lymph node is more important than the number of lymph nodes. Robot-assisted RNU may facilitate performing a meticulous LND compared with a laparoscopic approach. Postoperative complications such as lymphatic and/or chylous leakage are increased but adequately manageable. However, the current evidence is not supported by high-quality studies.
SUMMARY
Based on the published data, LND during RNU is a standard procedure for high-risk nonmetastatic UTUC, owing to its diagnostic, staging, prognostic, and, potentially, therapeutic benefits. Template-based LND should be offered to all patients who are planned for RNU for high-risk nonmetastatic UTUC. Patients with pN+ disease are optimal candidates for adjuvant systemic therapy. Robot-assisted RNU may facilitate meticulous LND compared with laparoscopic RNU.
Topics: Humans; Carcinoma, Transitional Cell; Urinary Bladder Neoplasms; Lymph Node Excision; Lymph Nodes; Nephroureterectomy; Retrospective Studies; Ureteral Neoplasms
PubMed: 37014743
DOI: 10.1097/MOU.0000000000001097 -
Journal of Minimally Invasive Surgery Mar 2019The most important advantages of laparoscopic gastrectomy are the minimal invasiveness, including less postoperative pain, shorter recovery, and minimal complications. A...
The most important advantages of laparoscopic gastrectomy are the minimal invasiveness, including less postoperative pain, shorter recovery, and minimal complications. A laparoscopic distal gastrectomy is accepted widely as a standard treatment for gastric cancer. On the other hand, a laparoscopic total gastrectomy has not been popularized as a distal gastrectomy because of the complexity of a lymph node dissection and the diversity of reconstruction. In terms of laparoscopic surgery for a remnant gastrectomy, there are three key points, which are critical for safe operation: adequate lymph node dissection, meticulous adhesiolysis, and reconstruction. After radical surgery for gastric cancer, the intra-abdominal condition is greatly changed. In addition, the lymphatic anatomy around the stomach is broken and surgeons should be aware of a newly developed lymphatic system to perform adequate node dissection. An esophago-jejunal reconstruction is at risk of leakage. Until evidence that is more concrete can be obtained, experienced surgeons should consider the laparoscopic approach.
PubMed: 35601704
DOI: 10.7602/jmis.2019.22.1.3 -
Sisli Etfal Hastanesi Tip Bulteni 2022Pancreaticoduodenectomy (PD) is one of the most challenging operations in gastrointestinal system due to the difficulty of dissection areas and the need for complex...
OBJECTIVES
Pancreaticoduodenectomy (PD) is one of the most challenging operations in gastrointestinal system due to the difficulty of dissection areas and the need for complex reconstruction. The aim of this study is to compare the morbidity, post-operative pancreatic fistula (POPF), and mortality rates of the cases we have from the learning period for minimally invasive PD and our previous open PD cases with similar fistula risk scores (FRSs).
METHODS
Patients with similar age, ASA score, pre-operative drainage, and FRS were included in the study. A total of 71 patients, 48 of whom were operated with open surgery and 23 with minimally invasive methods, were included in the study.
RESULTS
When the statistical analysis performed, no statistically significant difference was found between open surgery and minimally invasive surgery groups in terms of age, gender, ASA score, pre-operative drainage, pancreatic texture, and treatment of pancreatic leakage (p=0.27, p=0.09, p=0.4, p=0.39, p=0.76, and p=0.36, respectively). There was a statistically significant difference between two groups in terms of clinically relevant pancreatic anastomotic leakage (Grade-B and Grade-C fistula) (p=0.11). The rate of Grade-BL and B leakage was higher in the minimally invasive surgery group, while Grade-C fistula was not observed in any patient (p=0.002). However, there was no statistically significant difference between the two groups in terms of the management of pancreatic leakage and related morbidity (p=0.36). There was no significant difference between the two groups in terms of tumor size, number of lymph nodes removed, FRS, amount of intraoperative bleeding, and diameter of Wirsung and common bile duct (p=0.15, p=0.20, p=0.145, p=0.80, and p=0.073, respectively). Considering the operation time, it was found that the operation time was longer in patients who received minimally invasive surgical treatment and this was statistically significant (p<0.0001).
CONCLUSION
As a result, we believe that minimally invasive PD operation can be performed with similar morbidity and acceptable CR-POPF rates when compared with the open PD with similar FRS at the learning stage.
PubMed: 35990297
DOI: 10.14744/SEMB.2021.75350 -
BMC Surgery May 2022Carbon nanoparticle suspension (CNS) was applied to locate the lymphatic leakage in chylous ascites (CA). However, the flow speed and distance of the CNS were...
BACKGROUND
Carbon nanoparticle suspension (CNS) was applied to locate the lymphatic leakage in chylous ascites (CA). However, the flow speed and distance of the CNS were particularly decreased in the following two cases (patient 5 and 6). This study aimed to investigate and improve the flow speed and distance of the CNS via a rat model.
METHODS
Seven patients with CA were accepted for surgery in the past two years. Clinical data were recorded. Rats were divided into two groups to confirm the hypothesis regarding whether accepting milk or orally administered food before surgery was the key factor in CA surgery with CNS. The animals were divided into 2 groups: experimental group of 5 rats receiving fat emulsion injection (2 g/kg) 30 min before the operation and control group of 5 rats receiving saline. We analyzed flow speed and distance of the CNS in two groups of rats. The hypothesis established was that CNS movements pattern differ depending on the degree of capillary lymph duct filling. Finally, the late case reconfirmed the hypothesis again.
RESULTS
In animal experiments, the CNS in the preoperative high-fat feeding group moved faster and over a longer distance than that in the control group (0.51 ± 0.09 cm vs. 0.19 ± 0.10 cm, respectively; p < 0.05). Based on this, the CNS was applied to the seventh patient, who had been given a diet with a slightly higher fat content 3 days before the operation, and marked improvement with a complete cure was recorded.
CONCLUSIONS
The capillary lymph duct was beginning to swell after dietary intake. The dilation of the lymph vessel could make it easier for the CNS to move and reach the leakage.
Topics: Animals; Chylous Ascites; Humans; Lymphatic Vessels; Rats
PubMed: 35524233
DOI: 10.1186/s12893-022-01619-7 -
Gland Surgery Mar 2021Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from... (Review)
Review
Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.
PubMed: 33842273
DOI: 10.21037/gs-2019-ursoc-10 -
Journal of Vascular Surgery Jun 2022A previous meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy of closed incision negative pressure wound therapy (ciNPWT) on vascular surgery... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
A previous meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy of closed incision negative pressure wound therapy (ciNPWT) on vascular surgery groin wounds reported a reduction in surgical site infections (SSIs). Our aim was to perform a comprehensive, updated meta-analysis after the largest multicenter RCT on the subject to date reported no benefits from ciNPWT.
METHODS
A systematic review identified RCTs that had compared the primary outcome of the incidence of postoperative SSIs of groin incisions treated with ciNPWT or standard dressings. The secondary outcomes included wound dehiscence, a composite incidence of seroma, lymph leakage, and hematoma, the need for reoperation, in-hospital mortality, the need for readmission, and the hospital length of stay. The odds ratios (ORs) were compared across the studies using a random effects meta-analysis. The risk of bias was assessed using the Cochrane risk of bias tool, Harbord test, and trim-and-fill analysis.
RESULTS
Eight RCTs with 1125 incisions (ciNPWT, n = 555 [49.3%]; control, n = 570 [50.7%]) were included. The RCTs included three studies inside and five outside the United States. ciNPWT was associated with a significant reduction in the rate of SSIs (OR, 0.39; 95% confidence interval [CI], 0.24-0.63; P < .001). No significant differences were found in the rate of wound dehiscence (OR, 1.11; 95% CI, 0.67-1.83; P = .68), composite incidence of seroma, lymph leak, or hematoma (OR, 0.49; 95% CI, 0.13-1.76; P = .27), need for reoperation (OR, 0.68; 95% CI, 0.40-1.16; P = .16), or need for readmission (OR, 0.60; 95% CI, 0.30-1.21; P = .15). It was not possible to quantitatively evaluate in-hospital mortality or the hospital length of stay. The risk of bias assessment identified a high risk of bias for participant blinding in all eight studies, a low risk for randomization and outcome reporting, and variability between studies for the other methods. We found no evidence of publication bias.
CONCLUSIONS
Our meta-analysis of pooled data has suggested that prophylactic use of ciNPWT for vascular groin incisions will be associated with reduced rates of SSIs. The greatest benefits were seen in the trials with higher baseline rates of SSIs in the control group.
Topics: Groin; Hematoma; Humans; Multicenter Studies as Topic; Negative-Pressure Wound Therapy; Seroma; Surgical Wound; Surgical Wound Infection; Vascular Surgical Procedures
PubMed: 34999218
DOI: 10.1016/j.jvs.2021.12.070 -
The Journal of Surgical Research Apr 2021We have optimized a technique for cannulation of mesenteric lymph duct (MLD) in mice. Mice have low rates of intestinal lymph production; the MLDs are smaller and...
BACKGROUND
We have optimized a technique for cannulation of mesenteric lymph duct (MLD) in mice. Mice have low rates of intestinal lymph production; the MLDs are smaller and associated with fragile vasculature. Previous protocols for lymph collection based on the open lymph fistula model were associated with low success rates in mice. Bariatric surgery procedures worsen success rates due to postoperative adhesions and GI rearrangement. We have used this procedure to collect mesenteric lymph from mice undergoing bile diversion from gall bladder to ileum (GB-IL).
HYPOTHESIS
We hypothesize that peptide YY (PYY) levels in mesenteric lymph will increase following nutrient delivery in mice undergoing bile diversion from gall bladder to ileum (GB-IL).
METHODS AND RESULTS
We observe that cannulation of the MLD using a needled-catheter maintains lymph vessel integrity, prevents excessive lymph leakage, and is less traumatic, leading to high success rates (>95%). PYY levels in mesenteric lymph after GB-IL were significantly higher post nutrient infusion. The procedure takes approximately 20 min; small rodent surgical experience and practice are required for success.
CONCLUSIONS
Intestinal lymph can be collected from mice, including those undergoing bariatric surgical procedures with high success rates by cannulation of the mesenteric lymph duct.
Topics: Animals; Bariatric Surgery; Bile; Biliary Tract Surgical Procedures; Biomarkers; Catheterization; Female; Gallbladder; Ileum; Lymph; Lymphatic Vessels; Male; Mesentery; Mice; Mice, Inbred C57BL; Models, Animal; Peptide YY
PubMed: 33261855
DOI: 10.1016/j.jss.2020.11.004