目的:胸导管是人体最大的淋巴管,并将腹部器官吸收的液体和营养物质输送到中心静脉循环。胸导管阻塞可导致淋巴循环严重衰竭(即,蛋白质丢失性肠病,塑料支气管炎,等。).胸导管和中心静脉循环之间的外科吻合已用于治疗胸导管阻塞,但不能为上腔静脉阻塞或慢性中心静脉压升高的患者提供淋巴减压(例如,右心衰竭,单心室生理学,等。).因此,这项临床前可行性研究旨在开发一种新颖且最佳的手术技术,用于在猪中建立胸导管-肺静脉淋巴静脉吻合术(LVA),该技术可以保持通畅并保持单向淋巴液流入全身静脉循环,从而即使在中心静脉高压下也能提供淋巴循环的治疗性减压。
方法:在10只仔猪(中位年龄80[IQR80-83]天;体重22.5[IQR21.4-26.8]kg)中尝试了胸导管至肺静脉的LVA。在右侧开胸手术后,胸导管被动员起来,横切,吻合右下肺静脉.在术后第1天对动物进行全身抗凝。直到术后第7天,使用淋巴血管造影来评估LVA的通畅性。
结果:成功完成了8/10(80.0%)仔猪的胸导管至肺静脉LVA,其中6/8(75.0%)存活至预期研究终点,无任何并发症(中位数6[IQR4-7]天).最初,2/10(20.0%)LVAs术中中止,和2/10(20.0%)的动物由于术后并发症而早期安乐死。然而,使用优化的手术技术,在六只动物中建立胸导管至肺静脉LVA的成功率为100%,所有患者均存活至预期的研究终点,无任何并发症(中位数6[IQR4-7]天).LVAs保留专利长达7天。
结论:在全身抗凝治疗下,胸导管至肺静脉LVA可以安全完成,并保持至少一周的专利,这提供了一个重要的概念证明,即这种新颖的干预措施可以有效地减轻淋巴衰竭和中心静脉压升高的患者的淋巴循环负担。
OBJECTIVE: The thoracic duct is the largest lymphatic vessel in the body, and carries fluid and nutrients absorbed in abdominal organs to the central venous circulation. Thoracic duct obstruction can cause significant failure of the lymphatic circulation (i.e., protein-losing enteropathy, plastic bronchitis, etc.). Surgical anastomosis between the thoracic duct and central venous circulation has been used to treat thoracic duct obstruction but cannot provide lymphatic decompression in patients with superior vena cava obstruction or chronically elevated central venous pressures (e.g., right heart failure, single ventricle physiology, etc.). Therefore, this preclinical feasibility study sought to develop a novel and optimal surgical technique for creating a thoracic duct-to-pulmonary vein lymphovenous anastomosis (LVA) in swine that could remain patent and preserve unidirectional lymphatic fluid flow into the systemic venous circulation to provide therapeutic decompression of the lymphatic circulation even at high central venous pressures.
METHODS: A thoracic duct-to-pulmonary vein LVA was attempted in 10 piglets (median age 80 [IQR 80-83] days; weight 22.5 [IQR 21.4-26.8] kg). After a right thoracotomy, the thoracic duct was mobilized, transected, and anastomosed to the right inferior pulmonary vein. Animals were systemically anticoagulated on post-operative day 1. Lymphangiography was used to evaluate LVA patency up to post-operative day 7.
RESULTS: A thoracic duct-to-pulmonary vein LVA was successfully completed in 8/10 (80.0%) piglets, of which 6/8 (75.0%) survived to the intended study endpoint without any complication (median 6 [IQR 4-7] days). Initially, 2/10 (20.0%) LVAs were aborted intraoperatively, and 2/10 (20.0%) animals were euthanized early due to post-operative complications. However, using an optimized surgical technique, the success rate for creating a thoracic duct-to-pulmonary vein LVA in six animals was 100%, all of which survived to their intended study endpoint without any complications (median 6 [IQR 4-7] days). LVAs remained patent for up to seven days.
CONCLUSIONS: A thoracic duct-to-pulmonary vein LVA can be completed safely and remain patent for at least one week with systemic anticoagulation, which provides an important proof-of-concept that this novel intervention could effectively offload the lymphatic circulation in patients with lymphatic failure and elevated central venous pressures.