The thoracic duct (TD) transports ingested fat, drains lymph from the gastrointestinal vascular bed, and delivers the lymph to central veins in the neck. Preliminary evidence suggests that diversion of TD lymph may mitigate the severity of end-organ dysfunction in critical illness. Variations in the anatomy of the TD may determine whether reliable and safe cannulation of the duct, a necessary step for diversion, is possible. A systematic review was undertaken using the Google Scholar, MEDLINE, PubMed, and Scopus databases until 31st March, 2013. Both English and non-English articles were searched for, and surgical, cadaveric, and radiologic studies were included. Fifty-seven articles from the past 102 years were retrieved. There are significant variations in the anatomy of the TD in terms of its formation at the cisterna chyli, its course through the thorax, and its termination in the venous system. The most common site of termination is at the internal jugular vein (46%), followed by the jugulosubclavian angle (32%), and the subclavian vein (18%). An improved understanding of the anatomy of the TD would help surgeons to avoid inadvertent injury and potentially afford new opportunities for diagnosis and intervention in patients with critical illness.
Trevaskis et al. Allometry of Drug in Lymph following absorption. Overall, this study proposes that intestinal lymphatic flow, and lymphatic lipid and drug transport in humans is most similar to species with higher body mass such as dogs and underestimated by studies in rodents. Notably, lymph flow and lipid transport in humans can be predicted from animal data via allometric scaling suggesting the potential for similar relationships with drug transport.
A 90-year-old woman developed a large circular capsulorhexis-like defect in Descemet's membrane as a complication of small incision cataract surgery. Nine months post-surgery, in vivo confocal microscopic examination of the temporal mid-peripheral cornea revealed an endothelial cell density of 934 +/- 69 cells/mm2 (normal range 1566-3088 cells/mm2). Endothelial pigmented deposits were visible as scattered hyper-reflective areas on the posterior endothelial surface. Descemet's folds were also noted. In vivo confocal microscopy performed 3 years later showed the temporal mid-peripheral corneal endothelial density (in the region of the break) was 948 +/- 66 cells/mm2. A reduction of endothelial polymegathism and pleomorphism was observed. Imaging in the region of the temporal portion of the original Descemet's defect showed well-defined linear structures with hyper-reflective edges. Compared to 3 years previously, the cornea at the level of Descemet's membrane appeared to have greater reflectivity. This case demonstrates how microstructural changes in the cornea can be described and analysed over time with the assistance of in vivo confocal microscopy.
Liver abscess secondary to fish bone migration from the duodenuma ns_5665 206..214 A 59-year-old woman was admitted with persistent fever for 2 weeks in spite of medication treatment and progressive persistent epigastric dullness after fever onset 10 days later. Abdominal computed tomography revealed a linear high-density lesion between the liver abscess and the duodenal bulb. Percutaneous abscess drainage and antibiotics treatment were performed. The panendoscopy demonstrated a healed duodenal ulcer without any foreign body. Therefore, she underwent the lateral segmentectomy, fistulectomy and duodenorrhaphy. Operative findings revealed one 4-cm fish bone within the duodenohepatic fistula, which was located at the duodenal bulb attached to the liver (Fig. 1). She was discharged on post-operative day 12 and felt well during outpatient department follow-up.Liver abscess combined with hepato-enteric fistula is a rare clinical manifestation. There are two mechanisms of relation between liver abscess and hepato-enteric fistula. One is liver abscess rupture into alimentary tract. 1 The other is perforated bowel wall leading to liver abscess formation. 2 Intestinal perforation by foreign body ingestion is one of the bowel perforation factors and the incidence is approximately 1%. 2 In the past, liver abscess secondary to foreign body penetrating from the alimentary tract was a surgical indication. Recently, some reports suggest non-operative treatment by abscess drainage, antibiotics administration and endoscopic removal of foreign body. 2,3 We combined operative and non-operative therapy for this complicated case. According to the patient's history, the process by which this fish bone penetrated through the duodenal wall may be slow ongoing and migration is more likely. When it 'migrated' out of the duodenal serosa and then the fistular orifice was covered by new growing mucosa, this duodenohepatic fistula and the fish bone became invisible. This is the possible mechanism of the liver abscess secondary to fish bone migration from the duodenum. Kian Liun Phang, MBChB Bruce Peat, FRACS(Plast) Amber Moazzam, MB BS, FRCS(I), FRCS(Plast)
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.