Anatomy; Critical Illness; Intestines; Lymphatic System; Mesentery; Multiple Organ Failure; Pancreas; Physiology; Shock; Surgery; Thoracic Duct; Toxic Actions
Conflict of interest
The authors have no potential conflicts of interest
The intestine has been implicated in the pathophysiology of severe acute illness, including acute pancreatitis , trauma and hemorrhagic shock , and thermal injuries . The orthodox view is that development of a systemic inflammatory response and multiple organ dysfunction in these contexts is due to a failure in the intestinal barrier, bacterial translocation, portal bacteremia and endotoxemia . The potential for toxic intestinal factors to influence other splanchnic organs and induce a systemic response via mesenteric lymph while bypassing the portal circulation and liver is a more recent concept . This paper reviews the current state of knowledge regarding the anatomy, physiology and pathophysiology of mesenteric lymph. Particular attention is given to factors that influence mesenteric lymph composition and flow in acute illness, and how these might lead to new therapeutic approaches.
A search of the Ovid MEDLINE database through to January 2005 was done using the following search terms: mesentery, pancreas, bowel, small intestine, lymphatic system, intestinal lymph, mesenteric lymph, structure, composition and physiology. The search yielded 1,761 potentially relevant papers. The “Related References” feature of PubMed was used to identify further references. A manual search of citations for all pertinent references was also done to identify older papers.
The earliest known description of lymphatic vessels in the small intestine comes from the writings of the Alexandrian school (Herophilos, 335-280 BC and Erasistratus, 310-250 BC) [5, 6, 7]. Galen (129-199 AD) subsequently observed the intestinal lacteals when dissecting primates. Centuries later in 1622, Gasparo Aselli visualized the lacteals as “thin and beautiful white cords” in a well-fed dog and thought that he had discovered a fourth type of circulation. Aselli went on to demonstrate a relationship between lacteals and meals in unfed and fed dogs, and confirmed it in the human body by observing lacteals in a criminal executed after a large meal [7, 8, 9].
The earliest drawings of human lacteals appear in works by Johann Veslingius dated 1647 . Four years later, Jean Pecquet demonstrated flow of lymph from the intestinal lacteals to the cisterna chyli and thoracic duct in dogs  and humans . The term “lymphatics” was coined in 1653 by Bartholinus who, along with others, delineated the topography of lymphatics in various organs. In 1692, Anton Nück described the use of mercury injection to delineate fine lymphatic vessels and in 1787 Paolo Mascagni used this technique to map them, producing an elegant atlas of lymphatic anatomy. Philibert Sappey was possibly the first to count the valves of the lymphatics in 1874 .
These early anatomic studies paved the way for investigation of the physiologic func of lymphatics in the nineteenth and twentieth centuries. In 1858 Carl Ludwig postulated that lymph was a filtrate derived from the blood via the capillary wall by intracapillary pressure. In 1891 Rudolf Heidenhain challenged this hypothesis, contending that lymph was an active secretion by the lymphatic endothelium . Ernest Starling settled this debate by demonstrating that lymph is produced by the production of interstitial fluid due to the forces governing fluid movement across the capillary wall. These forces were the hydrostatic and colloid osmotic pressures both inside and outside the blood capillaries .
During the first half of the twentieth century, Drinker, Yoffey and Courtice  did a series of experiments on the lymphatic system using newly introduced electrophoretic techniques to investigate the protein fractions in plasma and lymph in different animal species. Moreover, they conducted experiments on the time-course of attaining equilibrium between plasma and lymph protein concentrations, and how this was affected by food intake and intravenous (i.v.) infusions of electrolyte solutions and vasoconstrictor drugs. They also estimated the daily bulk flow of lymph and extravascular protein in patients with thoracic duct fistulae.
Two developments in the second half of the twentieth century have further refined our understanding of mesenteric lymph. These were the development of organ transplantation and the evolving understanding that the intestine is not merely a passive bystander in critical illness, but may actually contribute to its severity. In transplantation research in the 1960s and 70s, there was an attempt to reduce the risk of organ rejection by depletion of lymphocytes using long term drainage of the thoracic duct [11, 12]. This approach found some acceptance in renal transplantation [13, 14]. Because thoracic duct drainage was typically performed three to four weeks before transplantation, there was the opportunity to study factors that influenced thoracic duct lymph volume and composition, including lymphocytes. The putative role of the intestine in the development of multiorgan failure in critically ill patients has been the subject of considerable investigation and debate. The initial focus was on bacterial translocation , but recent studies have extended the gut hypothesis beyond that, implicating mesenteric lymph rather than portal vein blood , as the exit route of gut-derived nonbacterial inflammatory factors. Unlike thoracic duct lymph, mesenteric lymph comes solely from the bowel with no contribution from other organs. This has provided direct and compelling evidence that the intestine is the source of the injurious factors.
Deitch et al. suggested that the intestinal contribution to distant organ injury in severe acute illness is mediated by a number of events or “multiple hits” . The first hit is intestinal ischemia, due to splanchnic vasoconstriction. This is followed by a reperfusion injury with resuscitation (second hit). The third hit arises from the interaction between pancreatic proteases and the ischemic bowel. The fourth hit results from translocation of intestinal bacteria and their products from the intestinal lumen into the gut wall where they can exacerbate the biological activity of mesenteric lymph.
Anatomy and Physiology
The central lacteal of the intestinal villus starts near the villus tip and courses axially down towards a network of submucosal lymphatic vessels. This network also receives tributaries from a plexus of lymphatic capillaries surrounding Peyer’s patches. The networks collectively form the efferent lymphatic trunks [5, 17] which then pass through mesenteric lymph nodes, often situated at the confluence of these trunks.
Mesenteric lymph nodes are small, beanshaped structures lying along the course of lymphatic vessels. They act as a filter for particulate matter and micro-organisms, and are the site of antigen presentation. Mesenteric lymph nodes have three components: lymphatic sinuses, blood vessels and parenchyma (cortex, paracortex and medulla). They contain lymphocytes (B- and T-cells), as well as macrophages and dendritic cells.
Mesenteric lymph nodes have been studied extensively in the context of bacterial translocation from the gastrointestinal tract, mainly in animals and in vitro models . Recently, Reddy et al. confirmed the translocation of commensal bacteria to mesenteric lymph nodes in surgical patientss , reporting that induction of IgA to commensal bacteria is confined to the mucosal immune system without systemic involvement, and that the extra-intestinal inflammatory response occurs when the host is immunocompromised or systemically ill.
In approximately two-thirds of patients the intestinal lymph trunk, which drains lymph from the stomach, intestines, pancreas, spleen and visceral surface of the liver, joins the right and left lumbar lymph trunks and smaller lymphatics from retroperitoneal structures to form the cisterna chyli. In a third of cases the intestinal trunk joins the left lumbar trunk and there is no cisterna chyli .
The cisterna chyli is located in front of the first and second lumbar vertebrae with the aorta on the left and the right crus of the diaphragm on the right . The cisterna chyli is a thin-walled structure which collapses in cadavers, so it was initially difficult to define its shape. Heavy T2- weighted magnetic resonance cholangiopancreatography images were used to define the shape and size of the cisterna chyli in vivo. The most common shapes were tubular (42.5%) plexiform (19.1%) and deltaic (12.5%). The mean (± standard deviation) longitudinal, anteroposterior, and transverse diameters were 33.45±1.74 mm, 5.20±0.13 mm and 5.23±0.15 mm, respectively .
The thoracic duct, exiting from the cisterna chyli, ascends into the thorax via the aortic hiatus and through the posterior mediastinum between the azygos vein and the aorta, on the anterior surface of the vertebral bodies. At the level of the fifth thoracic vertebra it curves to the left, enters the superior mediastinum posterior to the arch of the aorta, and continues upwards on the left side of the esophagus behind the left subclavian artery. At the root of the neck, the duct swings forward to drain into the neck veins, usually described as the junction of the left subclavian and internal jugular veins . However, the termination of the thoracic duct varies extensively. Kinnaert dissected 529 cadavers and found that the most common terminations of the thoracic duct were the internal jugular vein in 36% of the cases, the jugulosubclavian junction in 34%, and the subclavian vein in 17% . He also reported that thoracic duct termination was multiple in 21% of cases and that the thoracic duct occasionally bifurcated high in the thorax, with the left branch terminating as discussed earlier and the right branch diverging to join one of the right lymph trunks or even the right lymphatic duct, and the combined vessels emptying into the right subclavian vein.
The mean diameter of the thoracic duct is 5 mm at its abdominal origin and 4 mm at its termination in the neck, and its length is approximately 45 cm. A study in 30 cadavers has shown that the thoracic duct contains an average of 14.7 valves . This means that there is a valve every 3 cm along the length of the thoracic duct. At its termination there is a bicuspid valve to stop or diminish reflux of blood .
Valves allow the unidirectional transport of fluid from the interstitium into the initial lymphatics (irregular tissue cervices lined by a continuous attenuated endothelium) and then into the contractile lymphatics (containing a muscular wall capable of both tonic and phasic contraction). Schmid- Schonbein suggested that the initial lymphatics have a two-valve system, comprising a primary valve system at the level of the endothelium which prevents fluid escape into the interstitial space and a secondary intralymphatic valve system which prevents reflow along the lymphatic vessel .
The lymphangion is the morphologicfunctional unit of the lymphatic vessels [6, 25, 26]. It consists of a segment of lymphatic vessel located between two valves; the peripheral one belongs to one lymphangion and the central to the following one . The presence of valves and ampullary dilatation between them gives larger lymph vessels a beaded appearance. These vessels have smooth muscle in the regions between valves, but at the origin of the valves the lymphatic wall has little or no smooth muscle .
Anastomoses between the lymphatic vessels and veins have been described in various animal species [27, 28, 29] and are of potential physiologic and pathologic significance. Some studies have suggested that such communications only occur when there is obstruction to lymphatic flow [30, 31, 32, 33, 34]. Human studies have been limited to cancer patients and cadavers [35, 36, 37]. In his review of these studies, Barrowman concluded that lymphovenous communications do exist but only function with elevated lymphatic pressure . It has further been suggested that these lymphovenous shunts are also located within the lymph nodes [38, 39, 40], but their pathophysiological significance has not been explored.
Mesenteric lymph vessels and nodes are innervated by autonomic nerves [41, 42]. There is evidence of a dual (cholinergic and adrenergic) supply  but the innervation is less dense in lymphatics than in veins and arteries, lower in colon than in small bowel , and lower in mesenteric nodes than other lymph nodes . Adrenergic innervation of bovine mesenteric lymph has been shown to be capable of modulating lymphatic vasomotion as well as controlling lymph flow .
Mesenteric Lymph Composition
Studies of mesenteric lymph composition have been in the context of lymphatic leaks and chylomas [46, 47]. Changes in mesenteric lymph composition reflect its functions of maintaining fluid homeostasis  and blood pressure  by returning interstitial fluid to the systemic circulation. Mesenteric lymph also transports macromolecules and lipids , fat soluble vitamins  and water insoluble compounds . In addition, mesenteric lymph has an important role in the immune response . The composition of mesenteric lymph will be discussed with reference to its non-protein (electrolytes and lipids), protein (enzymes, hormones, iron, coagulation factors) and cellular components.
The electrolyte composition of thoracic duct lymph has been meticulously studied by Yoffey and Courtice  who presented the average values in fasting human subjects [53, 54, 55]. Total cations were marginally lower and total anions (chloride and bicarbonate) were higher in lymph than in plasma. These differences in ion concentration probably reflect the differences in protein composition between plasma and lymph, and are governed by the Gibbs-Donnan equilibrium. Calcium and magnesium concentrations are affected by their binding to proteins. Urea and creatinine concentration in lymph is similar to that in plasma . Iron concentration in mesenteric lymph is increased by oral [56, 57, 58] and i.v.  administration of iron and is probably bound to transferrin, as in plasma.
The lipid composition of mesenteric lymph has been studied extensively, particularly in relation to fat absorption or chylous effusion. The lipid content of intestinal lymph fluctuates widely depending on the type, extent and timing of fat ingestion. Chyle is a complex mixture of lymph and chylomicrons. Chylomicrons are the largest (1,000 nm) and the least dense (less than 0.95) of the lipoproteins. They are made up of 85 to 88% triglycerides, and approximately 8% phospholipids, 3% cholesterol esters, 1 to 2% proteins and 1% cholesterol. Chylomicrons contain several types of apolipoproteins including apo-AI, II and IV, apo-B48, apo-CI, II and III, apo-E and apo H. In chylous effusion cholesterol to triglyceride ratios are typically less than one. Fluid to serum triglyceride ratios greater than 2-3:1 are diagnostic for chylous effusion; ratios of 10- 20:1 are commonly encountered .
The protein and amino acid content of mesenteric lymph is relatively high but less than hepatic lymph [61, 62] and is usually around half the protein concentration of plasma . Yoffey and Courtice measured the protein content of lymph from various body regions in different animal species. In dogs for example, the average protein content of lymph from small bowel, liver and plasma was 3.2, 4.8 and 6.18 g/100 mL, respectively . This mesenteric lymph protein is derived from the plasma proteins, all of which are present in different proportions. Another important class of proteins are the immunoglobulins derived from the plasma cells of the lamina propria in the intestinal mucosa and mesenteric lymph nodes [8, 62]. Lymph clots, but less readily than plasma. The concentrations of fibrinogen and prothrombin in lymph vary, but are generally lower than the plasma concentration . Most investigators have studied the coagulation factors of thoracic duct lymph rather than mesenteric lymph. Mann et al. reported profound hypoprothrombinemia following drainage of mesenteric lymph in rats for 24 hours, which was corrected by i.v. administration of vitamin K despite the ongoing lymph loss . Hanley et al. measured activated partial thromboplastin time and prothrombin times in sheep mesenteric lymph and found that both were more prolonged in mesenteric lymph than in plasma .
A wide range of enzymes has been described in mesenteric lymph and thoracic duct lymph. The concentration of many enzymes is higher in lymph than in plasma. Lindena et al. summarized these studies in man and in four different animal species . They examined the concentrations of 16 enzymes in thoracic duct lymph and mesenteric lymph and concluded that these enzymes are primarily released from tissue cells into the interstitial space.
Alkaline phosphatase catalyzes hydrolysis of phosphoric esters and is a good example of an enzyme released by cells primarily into the interstitial space. The intestinal mucosa has a high concentration of alkaline phosphatase  which accounts for the higher concentration of alkaline phosphatase in mesenteric lymph than in plasma. The activity of alkaline phosphatase in plasma is greatly diminished following draining of mesenteric lymph, suggesting that mesenteric lymph is an important source of alkaline phosphatase . It has been found that alkaline phosphatase concentration in both plasma and mesenteric lymph increases after meals containing fat. This increased alkaline phosphatase activity in mesenteric lymph is greatly reduced or abolished if bile is excluded from the intestine .
Another example is pancreatic amylase which is secreted into the pancreatic duct then enters the intestinal lumen. To a much lesser extent this enzyme enters the pancreatic interstitial fluid and reaches the circulation via thoracic duct lymph. Amylase was found to be always present in the thoracic duct lymph of normal subjects  and its concentration to vary with fasting and feeding status . Although it has been suggested that the amylase in thoracic duct lymph could come from sources other than the pancreas, several investigators have shown that this amylase is pancreatic in origin. Dumont et al. studied human thoracic duct lymph amylase levels in both the resting and stimulated pancreas and found that i.v. secretin produced a marked increase in thoracic duct lymph amylase concentration without significant changes in serum amylase levels . They also reported that morphine co-administered with secretin augmented this effect and that a sharp rise in thoracic duct lymph amylase levels occurred during gentle handling of the pancreas
Bartos et al. studied 40 fasting patients with a variety of gastrointestinal diseases, and reported that amylase levels in thoracic duct lymph exceeded those in blood when the pancreas was stimulated by administration of a combination of secretin and pancreozymin or secretin and morphine . Following thoracic duct lymph diversion, the increase in serum amylase in response to pancreatic stimulation was markedly diminished.
Singh et al. suggested that the liver and the small intestine make no contribution to serum amylase via the lymph, reporting that the increase of serum and lymph amylase following i.v. secretin is abolished by pancreatectomy in dogs .
Certain lysosomal enzymes appear in thoracic duct lymph in shock and have been implicated in the pathogenesis of distant organ failure. Details of relevant experiments are discussed later in this review.
The hormonal composition of mesenteric lymph has been studied. Insulin levels have been found to be consistently lower in thoracic duct lymph than in plasma in both humans  and animal models [74, 75, 76]. This suggests that most lymphatic insulin is derived from the plasma by filtration. Another possible source of insulin in thoracic duct lymph is pancreatic lymph. Lymphatic transport of insulin bypasses the liver, which is known to clear 40 to 50% of insulin transported via portal blood. The i.v. administration of glucose did not produce increased insulin levels in cisterna chyli lymph in rats  or in thoracic duct lymph in dogs , confirming that insulin enters the circulation primarily by direct secretion rather than by lymphatic transport. Other intestinal hormones have been detected in thoracic duct lymph and are all present at low concentrations in the resting state. Svatos et al. reported that cholecystokinin levels were very low in fasting patients with gastrointestinal disease, but increased significantly after intraduodenal infusion of sorbitol . Whether or not there is any physiologic role for hormones in mesenteric lymph has not been determined.
Gut-associated lymphoid tissue (GALT) is an important secondary lymphoid tissue. It makes a major contribution to the lymphocytes present in mesenteric lymph, thoracic duct lymph and the systemic circulation. It was first demonstrated in rabbits in 1940 by Erf, who showed that removal of the stomach and intestine produced lymphopenia which was notworsened by removal of other lymphatic tissue . Reinhardt and Yoffey confirmed this in guinea pigs by showing a greater than 95% reduction in thoracic duct lymphocytes following enterectomy . The output of lymphocytes in mesenteric lymph draining regions with Peyer patches is higher than that of lymphocytes draining areas without Peyer patches  and contains more newly formed T than B lymphocytes . Mesenteric lymph contains lymphocytes as well as nonlymphoid cells such as veiled (dendritic) cells . The lymphocytes consist of CD2+ cells (mainly CD8+ and CD4+), immunoglobulinpositive cells (IgM and IgA) and null cells (unstimulated lymphocytes). Thielke et al. identified subsets of lymphocytes in female minipigs, showing that the approximate proportions of CD2+, immunoglobulinpositive cells and null cells were 80%, 10% and 10%, respectively . CD4+ T helper cells (about 39.5%) outnumbered CD8+ T cytotoxic/suppressor cells (about 30.2%). IgM cells (about 9.2%) also outnumbered IgA cells (about 1.2%).
Lemaire et al. identified leucocytes in both thoracic duct lymph and peripheral blood in patients undergoing resection of esophageal or gastro-esophageal cancers, and found comparable proportions of B lymphocytes (14.5% vs. 11.9% for thoracic duct lymph and peripheral blood, respectively), T lymphocytes (78.1% vs. 78.2%) and CD8+ cells (23% vs. 25.2%) . Compared with peripheral blood, thoracic duct lymph contained proportionately more CD4+ cells (59.6% vs. 40.3%, respectively) and more CD4+CD45RO+ and CD8+CD45RO+ expressing alpha4beta7 cells (41.6% vs. 17.7% and 59.5% vs. 33.3%, respectively). These data suggest an equivalent B and T lymphocyte recirculation rate, and a more active recirculation of CD4+ than CD8+ cells, and a more active recirculation of memory cells to the gut than to other extralymphoid sites.
Farstad et al. reported that human mesenteric lymph obtained from three organ donors contained naïve T and B lymphocytes (approximately 60% and 25%, respectively), memory T and B lymphocytes (about 10%) and B-cell blasts (about 2%) . Other blood cells such as platelets are nearly or entirely absent, while erythrocytes are constantly present in chyle [5, 85].
Mesenteric Lymph Flow
Thoracic duct lymph comprises about 90% of total lymph flow  in anesthetized animals but probably about 50 to 70% in the conscious animal . The daily thoracic duct lymph flow in humans is about 24 to 48 mL/kg  but increases up to 120 mL/kg in ruminants . Under normal resting conditions thoracic duct lymph is derived largely from the abdominal viscera [88, 89], (mainly the intestine and liver) [88, 90, 91] with minor contributions from the trunk, lower extremities  and intrathoracic structures . The relative contribution of mesenteric lymph to total thoracic duct lymph exceeds the liver contribution in cats , rats  and ruminants [93, 94].
Factors modulating mesenteric lymph as well as diseases reported to be associated with abnormal mesenteric lymph flow are summarized in Table 1. These factors might be used to alter the course of diseases in which mesenteric lymph has a role. The centripetal forces producing lymph flow can be classified as extrinsic (passive lymph pump) or intrinsic (active lymph pump). Extrinsic forces include skeletal muscle activity, central venous pressure, gastrointestinal peristalsis, pulsation of blood vessels, gravity and respiration . Intrinsic forces are the coordinated contraction of a chain of lymphangions. These contractions are initiated by pacemaker activity in smooth muscle cells in the lymphangion wall. Factors which modulate this pacemaker activity can be broadly classified as neural, humoral, pharmacologic and mechanical. In certain conditions, such as hemorrhage, more than one factor can influence intrinsic pump activity. The mechanisms by which these factors exert their effects on the intrinsic pump are not well defined, but appear to differ between different animals and humans. There are also profound differences between the pressure and flow sensitivities of different lymphatic vessels, including the thoracic duct and mesenteric lymphatics . Factors affecting the intrinsic pump are listed in Table 2.
Mesenteric Lymph and Disease
The literature contains many studies that have investigated changes in thoracic duct lymph and mesenteric lymph flow and composition in a variety of diseases. There is now evidence to show that mesenteric lymph plays a key role in the pathogenesis of multiorgan dysfunction in trauma/hemorrhagic shock [2, 15, 96, 97, 98], burn [99, 100], surgical stress [101, 102] and reperfusion injury [103, 104, 105].
The mesenteric lymph factors active in these diseases and the way in which they exert their effects are poorly understood. They include serine protease , oxidative stress , phospholipase A2 [108, 109] and apoptotic factors . The lack of understanding is highlighted by the range of opinions that the active factor is in the lipid fraction [111, 112], in the protein-aqueous fraction , is a modified form of albumin [114, 115], is greater than 100 kD , and could be a 24- amino acid peptide . Other studies have suggested that the effect of toxic mesenteric lymph is not due to its cellular component , translocating bacteria, endotoxin, cytokines or xanthine oxidase [2, 117]. It is likely that the effect of toxic mesenteric lymph is mediated by a combination of factors, and they may or may not be different in various disease states.
Studies in Hemorrhagic Shock and Trauma
Experiments from around 1940 suggested the “shock-delaying” action of barbiturates  in contrast with ether anesthesia, which was associated with a more rapid onset of shock  in the context of intestinal injury. It appears that these different effects are attributable to the known actions of these agents with regard to mesenteric lymph flow. Ether causes an increase and barbiturates causes a decrease in lymph flow (see Table 1) .
Segmental intestinal resection has been reported to have a favourable impact on the outcome from endotoxic  and hemorrhagic shock . This was in contrast with the finding that segmental exclusion of the small intestine (by jejunal or ileal stoma) did not improve survival in hemorrhagic shock [123, 124]. Segmental resection, unlike segmental exclusion, appeared to reduce mesenteric lymph volume and flow. Total intestinal exclusion/excision was associated with an adverse outcome secondary to malnutrition . In a more recent study, the influence of malnutrition was negated in rats by performing a total enterectomy, i.e. resection of both the small and large intestine, and simultaneous induction of hemorrhagic shock. Enterectomized rats were found to have a significant improvement in survival .
Other potential lymphatic mediators of distant organ injuries have been studied, including lysosomal enzymes. Dumont and Weissmann found that there was a significant increase in thoracic duct lymph beta glucuronidase in dogs that were bled to death, which was not found with diversion of thoracic duct lymph . This finding could not be confirmed in a study of less severe hemorrhagic shock, in which the levels of three lysosomal enzymes (beta glucuronidase, acid phosphatase, leucine aminopeptidase) were higher in plasma than in thoracic duct lymph and thoracic duct diversion did not prevent this .
Diversion of thoracic duct lymph has been shown in a feline model to have a beneficial effect on the outcome of hemorrhagic shock . There was a three-fold increase in survival duration in animals with thoracic duct lymph diversion (156±12.8 min) compared with controls (52±4.1 min).
Ligation of the mesenteric duct also appears to have a protective effect. Deitch et al. have identified a number of changes that occur in this context, and in a variety of models. The relative contributions of these to outcome have not been determined. They include activation of neutrophils, cytotoxicity to endothelial cells with increased permeability and apoptosis, and upregulation of endothelial adhesion molecules [113, 129, 130, 131, 132, 133], decreased red cell deformability , hematopoietic failure  and impaired cardiac contractility .
Studies of Intestinal Ischemia
The intestine is particularly susceptible to ischemia because of the anatomy of the villus microcirculation. The countercurrent arrangement of veins around a central arteriole allows for arteriovenous shunting of oxygen and causes anoxia of the villus tip . During ischemia, mucosal acidosis and ATP depletion  develop quickly and epithelial cells separate from the villi . Reperfusion of the intestine exacerbates injury due to production of oxygen free radicals , nitric oxide derived radicals , cytokines , and activation of the complement system . These factors lead to local injury and recruitment of leukocytes that exacerbate the injury. Ischemic damage to the intestine has at least two major effects. The first effect is that the intestinal barrier integrity becomes compromised, allowing bacterial translocation . With breakdown of the intestinal barrier, bacteria and toxins translocate to mesenteric lymph nodes  causing generation of more cytokines and activated leukocytes. As a result, the intestinal interstitial fluid is awash with cellular debris, cytokines, bacteria, activated leukocytes and oxygen radicals. The second effect is that the intestine, an “endocrine organ” in its own right, is stimulated to release a large number of pro-inflammatory mediators . These effects on the intestine drive the development of multiple organ dysfunction syndrome (MODS) [147, 148].
In order to study the effect of intestinal ischemic injury on other diseases it is necessary to use an animal model that maintains perfusion of other organs. Kozar et al. compared three animal models of intestinal ischemia/reperfusion, i.e. controlled hemorrhage, uncontrolled hemorrhage and superior mesenteric artery occlusion (SMAO) . They concluded that superior mesenteric artery occlusion is a simple and reproducible model, and a clinically relevant one for shockinduced intestinal ischemia/reperfusion. Using the superior mesenteric artery occlusion model of intestinal ischemia reperfusion in rats, Cavriani et al.  reported that the resulting intestinal and lung injuries were partially mediated by tumor necrosis factor and that they were prevented by ligation of the thoracic duct. The concentration of leukotriene B4 has been shown to increase in mesenteric lymph (but not portal blood) following occlusion of the descending aorta in a feline model. Leukotriene B4 is known to sensitize afferent nerve endings, but it is unknown whether it has any role in mediation of the adverse effects of intestinal ischaemia .
Studies of Acute Pancreatitis
Thoracic duct lymph contains amylase in normal subjects and the concentration increases dramatically in acute pancreatitis . Furthermore, Brzek and Bartos found that amylase levels were higher in thoracic duct lymph than in blood during acute pancreatitis . It is not known whether this increase in pancreatic enzymes in thoracic duct lymph has an adverse effect on the outcome of acute pancreatitis.
Several studies have investigated the effect of small intestinal exclusion or small intestinal resection on the course of acute pancreatitis. Kiriakou et al. divided dogs into three groups; acute pancreatitis only, acute pancreatitis plus small bowel exclusion, and acute pancreatitis plus small bowel resection. The first two groups survived from 90 minutes to 12 hours, while most of the third group survived for up to two weeks .
Recently, it has been shown that mesenteric lymph in acute pancreatitis is injurious to the red blood cells. The decrease in red blood cells deformability was partially prevented by mesenteric duct ligation .
Schmid-Schonbein and Hugli have published a hypothesis which could help to explain the mechanism by which biologically active lymph was generated in acute pancreatitis in the above experiment. They suggest that when the gut mucosal barrier is compromised, as in acute pancreatitis , pancreatic digestive enzymes which are not normally able to cross the mucosal barrier become able to penetrate the submucosal space of the small bowel and release inflammatory mediators via mesenteric lymph, the portal vein and the peritoneum .
Interventions Directed at Mesenteric Lymph
In the absence of any clear understanding of what is responsible for the toxicity of mesenteric lymph, it is not surprising that a broad range of interventions targeted towards mesenteric lymph has been investigated. In various animal models, these have included peripheral infusion of hypertonic saline [157, 158, 159], Ringer’s ethyl pyruvate  and albumin . Another approach has been to instil sodium pyruvate , L-arginine , serine protease inhibitors [106, 164, 165], and edaravone (a free radical scavenger)  within the intestinal lumen. The other broad approach taken has been of a more procedural nature, including global hypothermia , ligation of the pancreatic [16, 168, 169], mesenteric [15, 131, 132, 135, 170, 171, 172, 173, 174, 175, 176, 177, 178] and thoracic  ducts, and external drainage of thoracic duct lymph [135, 177].
The timing of intervention needs to be considered. Mesenteric lymph becomes biologically active during trauma/ hemorrhagic shock prior to resuscitation, and persists for several hours after resuscitation . Therefore, it is desirable to intervene as early as possible to reduce the adverse effects of critical illness.
Lymphatic flow can be modulated by medical therapies, as shown in Table 1. Morphine and barbiturates reduce mesenteric lymph/thoracic duct lymph flow, while noradrenaline and dopamine increase mesenteric lymph/thoracic duct lymph flow. Sympathomimetic drugs, at certain doses, can cause spasm of the lymphatic vessels and decrease mesenteric lymph flow [42, 179]. Chlorthiazide 20 mg/kg produces either no change or a very modest increase in mesenteric lymph, while furosemide 10 mg/kg greatly enhances mesenteric lymph .
The intestine and mesenteric lymph have efficient and intrinsic anti-oxidant defenses  but these can be overwhelmed by oxidative stress . Early antioxidant therapy during hemorrhagic shock has been shown to improve survival in rats . The idea of using the available lipophilic antioxidants such as U-74500A, U-74389G and U-74006F in this setting is appealing. Transport of these drugs by mesenteric lymph is slower than in portal blood and hence the lymph is targeted directly and efficiently. These orally active antioxidants also bypass the hepatic first-pass mechanism , and can be administered with enteral nutrition. It has been reported that infusion of U-74006F into rats has a protective effect in ischemic reperfusion injury of the bowel caused by splanchnic artery occlusion .
This suggests that modulation of lymphatic flow by medical therapy is worth exploring. Some of the other factors listed in Table 1 that decrease mesenteric lymph flow might be examined more critically in this context, such as hypothermia and use of the reverse Trendelenberg position to increase central venous pressure
Nutritional Support of the Intestine
Early enteral nutrition in the critical care setting has been shown to be superior to total parenteral nutrition (TPN) [184, 185, 186, 187, 188, 189]. However, it should be recognized that enteral nutrition will increase mesenteric lymph flow [8, 190], especially the lipid component. This might explain why enteral nutrition did not ameliorate the inflammatory response in patients with prognostically severe acute pancreatitis . Conversely, TPN in the absence of oral food intake will decrease mesenteric lymph flow by not providing enteral nutrients for absorption [192, 193]. Both fat free/low fat enteral nutrition and TPN have been shown to decrease lymph output in the treatment of chyle leak [194, 195, 196]. Enteral nutrition has also been shown to be superior to TPN in the context of critical illness, and further studies are required to compare the outcome of using low fat enteral nutrition and standard enteral nutrition in critical illness.
Whether immune-enhanced enteral nutrition is superior to standard enteral nutrition remains controversial [197, 198, 199]. Larginine and glutamine regulate NO synthesis , so potentially could modulate the intrinsic lymphatic pump and mesenteric lymph flow. This mechanism warrants further investigation.
There are three ways to prevent mesenteric lymph from entering the peripheral circulation: mesenteric duct ligation, thoracic duct ligation and thoracic duct external drainage.
Mesenteric Duct Ligation
There are numerous animal studies demonstrating that mesenteric duct ligation can prevent distant organ failure [131, 132, 170, 171, 172]. There appear to be five problems in applying their findings to the clinical setting. Firstly, humans do not always have a well-defined intestinal trunk to be ligated . Secondly, mesenteric duct ligation results in steatorrhoea. This can be mitigated by diverting the lymph into the urinary bladder, the peritoneum or pleural cavities . Thirdly, timing of mesenteric duct ligation in the animal experiments was before induction of hemorrhagic shock, which is prior to the therapeutic window in the clinical setting. Fourthly, some mesenteric lymph will reach the thoracic duct despite mesenteric duct ligation , possibly via lymphovenous communications (see earlier)  and the extent of this is impossible to predict. Fifthly, mesenteric duct ligation is not a durable approach, which may be therapeutically advantageous, because mesenteric lymph can reverse flow to bypass an obstruction  and regenerate [205, 206]. Unfortunately there are no clinical studies of this.
Thoracic Duct Ligation
Thoracic duct ligation is reasonably well tolerated in both humans and animals [32, 207]. It causes a type of intestinal atrophy which is morphologically similar to malabsorption syndrome but without any associated functional changes . Thoracic duct ligation in patients with chylothorax is without major sequelae, and was recommended to be undertaken as a routine step in an esophagectomy for cancer . A recent report suggests that thoracic duct ligation prior to induction of bowel ischemia/reperfusion in rats causes a reduction in lung injury in models of trauma and hemorrhagic shock .
Toxic mesenteric lymph in an acute pancreatitis rat model demonstrated proinflammatory properties , so it could be hypothesized that thoracic duct ligation should result in an improved outcome. However, this has not been found, and the evidence available suggests that thoracic duct ligation has a negative impact on the normal, stimulated pancreas and in acute pancreatitis. Blalock et al. showed that the normal pancreas in dogs developed lymphedema as a result of chronic lymphatic obstruction at the level of cisterna chyli or thoracic duct at the neck . Dumont et al. used secretin and bethanechol to stimulate the pancreas in dogs. Subcutaneous injection of their thoracic duct lymph into rabbits resulted in acute inflammation of skin and subcutaneous tissues. Thoracic duct ligation made the lymph more toxic and caused severe inflammation of the rabbit skin and subcutaneous tissues . In a rat model of trypsin-induced pancreatitis thoracic duct ligation resulted in a significant increase in mortality [212, 213].
Thoracic Duct External Drainage
In contrast with thoracic duct ligation which has had limited application, external drainage of the thoracic duct  has been investigated in a variety of diseases, and mainly in Eastern Europe. These diseases are listed in Table 3. In 1989 Dugernier et al. reported that thoracic duct external drainage for up to 10 days resulted in a dramatic improvement in pulmonary gas exchange, circulatory status and survival in patients with severe acute pancreatitis and respiratory failure . The relatively short period of drainage in this study avoided possible complications associated with long term thoracic duct external drainage (for one to three months), such as humoral and cellmediated immune suppression. Bondarev et al. used thoracic duct external drainage with further lymphosorption (extracorporeal purification and reinfusion of purified lymph) successfully in the treatment of acute pancreatitis .
Later in 2003 Dugernier et al. investigated compartmentalization of the cytokine response in 60 patients with severe acute pancreatitis . The investigators measured levels of 11 pro- or anti-inflammatory cytokines in ascitic fluid, thoracic duct lymph and plasma, and found that thoracic duct external drainage over a period of 6 days had no effect on circulating cytokine levels. Their finding reinforced the view that thoracic duct external drainage is ineffective in the treatment of severe acute pancreatitis . However, this study had two noteworthy shortcomings. Firstly, thoracic duct external drainage was done in patients with preexisting involvement of at least one organ, This indicates that significant damage had already been done because mesenteric lymph has maximum biological activity in the first few hours of critical illness . Secondly, it is not clear if thoracic duct external drainage was complete, given that the duct may bifurcate or have multiple terminal openings. A more definitive study evaluating thoracic duct external drainage as an early intervention in critically ill patients is warranted.
The role of mesenteric lymph in pathogenesis of distant organ failure in critically ill patients has been highlighted by a number of studies over the last two decades. This focused review of the early and recent literature was warranted to highlight the gaps in current understanding of the role of mesenteric lymph in health and disease. This review demonstrates a need for further investigations in several areas. Firstly, there is a need to identify the factors responsible for generating biologically active mesenteric lymph. Secondly, there is a need to clarify the role of drugs modulating mesenteric lymph flow/composition and that of intrinsic pump activity in preventing distant organ failure. Thirdly, the action of lipophilic antioxidant drugs in mesenteric lymph needs further investigation. Fourthly, the impact of low fat enteral nutrition should be compared with standard enteral nutrition. Fifthly, there is a need for studies comparing the effects of thoracic duct ligation with thoracic duct external drainage.
- Leveau P, Wang X, Sun Z, Borjesson A, Andersson E, Andersson R. Severity of pancreatitisassociated gut barrier dysfunction is reduced following treatment with the PAF inhibitor lexipafant. Biochem Pharmacol 2005; 69:1325-31. [PMID 15826603]
- Deitch EA. Role of the gut lymphatic system in multiple organ failure. Curr Opin Crit Care 2001; 7:92- 8. [PMID 11373517]
- Gosain A, Gamelli RL. Role of the gastrointestinal tract in burn sepsis. J Burn Care Rehabil 2005; 26:85- 91. [PMID 15640741]
- Deitch EA, Xu D, Kaise VL. Role of the gut in the development of injury- and shock induced SIRS and MODS: the gut-lymph hypothesis, a review. Front Biosci 2006; 11:520-8. [PMID 16146750]
- Yoffey JM, Courtice FC. The formation of lymph in lymphatics, lymph and the lymphomyeloid complex. Edited by Yoffey and Courtice, London, Academic Press, pp 123–132, 1970.
- Browse NL. Diseases of the lymphatics. In: Browse NL, Burnard KG, Mortimer PS, eds. London: Arnold, 2003.
- Kanter MA. The lymphatic system: an historical perspective. Plast Reconstr Surg 1987; 79:131-9. [PMID 3541012]
- Barrowman J. Physiology of the gastrointestinal lymphatic system. Cambridge: Cambridge University Press, 1978.
- Mayerson HS. On lymph and lymphatics. Circulation 1963; 28:839-42. [PMID 14079186]
- Leeds SE. Three centuries of history of the lymphatic system. Surg Gynecol Obstet 1977; 144:927- 34. [PMID 324006]
- Murray JE, Wilson RE, Tilney NL, Merrill JP, Cooper WC, Birtch AG, et al. Five years' experience in renal transplantation with immunosuppressive drugs:survival, function, complications, and the role of lymphocyte depletion by thoracic duct fistula. Ann Surg 1968; 168:416-35. [PMID 4175449]
- Sharbaugh RJ, Fitts CT, Majeski JA, Wright FA, Hargest TS. The efficacy of closed-circuit extracorporeal filtration of thoracic duct lymph as a means of lymphocyte depletion. Clin Exp Immunol 1972; 12:255-62. [PMID 4648823]
- Starzl TE, Weil R 3rd, Koep LJ, McCalmon RT Jr, Terasaki PI, Iwaki Y, et al. Thoracic duct fistula and renal transplantation. Ann Surg 1979; 190:474-86. [PMID 384943]
- Fish JC, Sarles HE, Remmers A Jr, Townsend CM Jr, Bell JD, Flye MW. Renal transplantation after thoracic duct drainage. Ann Surg 1981; 193:752-6. [PMID 7018426]
- Magnotti LJ, Upperman JS, Xu DZ, Lu Q, Deitch EA. Gut-derived mesenteric lymph but not portal blood increases endothelial cell permeability and promotes lung injury after hemorrhagic shock. Ann Surg 1998; 228:518-27. [PMID 9790341]
- Cohen DB, Magnotti LJ, Lu Q, Xu DZ, Berezina TL, Zaets SB, et al. Pancreatic duct ligation reduces lung injury following trauma and hemorrhagic shock. Ann Surg 2004; 240:885-91. [PMID 15492572]
- Granger DN, Barrowman JA. Microcirculation of the alimentary tract I. Physiology of transcapillary fluid and solute exchange. Gastroenterology 1983; 84:846- 68. [PMID 6337911]
- Berg RD. Bacterial translocation from the gastrointestinal tract. Adv Exp Med Biol 1999; 473:11- 30. [PMID 10659341]
- Reddy BS, Macfie J, Gatt M, Macfarlane-Smith L, Bitzopoulou K, Snelling AM. Commensal bacteria do translocate across the intestinal barrier in surgical patients. Clin Nutr 2007; 26:208-15. [PMID 17208338]
- Freitas RA Jr. Nanomedicine. Volume I: Basic Capabilities. Georgetown, TX, USA: Landes Bioscience, 1999.
- Williams PL, Warwick R, Dyson M, Bannister LH. Gray's Anatomy. 37th edition. Edinburgh, United Kingdom: Churchill Livingstone, 1989.
- Erden A, Fitoz S, Yagmurlu B, Erden I. Abdominal confluence of lymph trunks: detectability and morphology on heavily T2-weighted images. AJR Am J Roentgenol 2005; 184:35-40. [PMID 15615947]
- Petrenko VM, Kruglov SV. Thoracic duct valves in man and albino rat. Morfologiia 2004; 126:40-2. [PMID 15839250]
- Schmid-Schonbein GW. The second valve system in lymphatics. Lymphat Res Biol 2003; 1:25-9. [PMID 15624318]
- Gashev AA. Physiologic aspects of lymphatic contractile function: current perspectives. Ann N Y Acad Sci 2002; 979:178-87. [PMID 12543727]
- Borisov A. The theory of the design of the lymphangion. Morfologiia 1997; 112:7-17. [PMID 9460671]
- Silvester CF. On the presence of permanent communications between the lymphatic and the venous system at the level of the renal veins in adult South American monkey. Am J Anat 1911; 12:447-60.
- Roddenberry H, Allen L. Observations on the abdominal lymphaticovenous communications of the squirrel monkey (Saimiri sciureus). Anat Rec 1967; 159:147-57. [PMID 4966185]
- Azzali G, Didio LJ. The lymphatic system of bradypus tridactylus. Anat Rec 1965; 153:149-60. [PMID 5867110]
- Yamagata K, Kumagai K, Yasui A, Uchida R. The possibility of lymphaticovenous communication induced by the mesenteric lymph vessels obstruction. Nippon Shokaki Geka Gakkai Zasshi 1994; 27:2500.
- Carlsten A, Olin T. The route of the intestinal lymph to the blood stream; roentgenological study in cats. Acta Physiol Scand 1952; 25:259-66. [PMID 12976143]
- Marshall WH Jr, Neyazaki T, Abrams HL. Abnormal protein loss after thoracic-duct ligation in dogs. N Engl J Med 1965; 273:1092-4. [PMID 5834822]
- Takashima T, Benninghoff DL. Lymphaticovenous communications and lymph reflux after thoracic duct obstruction. An experimental study in the dog. Invest Radiol 1966; 1:188-97. [PMID 4287197]
- de Freitas V, Zorzetto NL, Prates JC, Seullner G. Experimental study of lymphatico-venous communications after thoracic duct ligature in dogs. Anat Anz 1979; 146:27-38. [PMID 525810]
- Edwards JM, Kinmonth JB. Lymphovenous shunts in man. Br J Surg 1969; 56:699. [PMID 5808403]
- Sapin MR., Etingen LE. Lymphovenous anastomoses. Do they exist? Arkh Anat Gistol Embriol 1975; 68:98-101. [PMID 50838]
- Threefoot SA, Kossover MF. Lymphaticovenous communications in man. Arch Intern Med 1966; 117:213-23. [PMID 5901553]
- Pressman JJ, Simon MB. Experimental evidence of direct communications between lymph nodes and veins. Surg Gynecol Obstet 1961; 113:537-41. [PMID 14488657]
- Hidden G, Menard P, Zorn JY. Lymphaticovenous communications. Role of the lymph nodes. Anat Clin 1985; 7:83-91. [PMID 4041277]
- Pressman JJ, Dunn RF, Burtz M. Lymph node ultrastructure related to direct lymphaticovenous communication. Surg Gynecol Obstet 1967; 124:963- 73. [PMID 4960593]
- Alessandrini C, Gerli R, Sacchi G, Ibba L, Pucci AM, Fruschelli C. Cholinergic and adrenergic innervation of mesenterial lymph vessels in guinea pig. Lymphology 1981; 14:1-6. [PMID 7289657]
- McHale NG. Lymphatic innervation. Blood Vessels 1990; 27:127-36. [PMID 1700733]
- Wang XY, Wong WC, Ling EA. Studies of the lymphatic vessel-associated neurons in the intestine of the guinea pig. J Anat 1994; 185:65-74. [PMID 7559116]
- Chzhao L, Shvalev VN. Adrenergic innervation of lymph nodes and the thoracic duct. Arkh Anat Gistol Embriol 1989; 96:33-7. [PMID 2764737]
- McHale NG, Roddie IC, Thornbury KD. Nervous modulation of spontaneous contractions in bovine mesenteric lymphatics. J Physiol 1980; 309:461-72. [PMID 7252876]
- Teba L, Dedhia HV, Bowen R, Alexander JC. Chylothorax review. Crit Care Med 1985; 13:49-52. [PMID 3917388]
- Keough KM, Hawco M, Acharya S, Malatjalian DA, Snedden W, Kwan A, Barrowman JA. A chylous mesenteric cyst and a study of its contents. Dig Dis Sci 1979; 24:797-801. [PMID 487917]
- Zhang J, Liu YK, Jiang H, Ge L, Shi MJ, Zhang LM. Effect of intestinal lymph on blood pressure of rat. Sheng Li Xue Bao 1997; 49:433-8. [PMID 9812876]
- O'Driscoll CM. Lipid-based formulations for intestinal lymphatic delivery. Eur J Pharm Sci 2002; 15:405-15. [PMID 12036717]
- Mann JD, Higgins GM. Lymphocytes in thoracic duct intestinal and hepatic lymph. Blood 1950; 5:177- 90. [PMID 15402274]
- Hauss DJ, Fogal SE, Ficorilli JV, Price CA, Roy T, Jayaraj AA, Keirns JJ. Lipid-based delivery systems for improving the bioavailability and lymphatic transport of a poorly water-soluble LTB4 inhibitor. J Pharm Sci 1998; 87:164-9. [PMID 9519148]
- Wu TF, MacNaughton WK, von der Weid PY. Lymphatic vessel contractile activity and intestinal inflammation. Mem Inst Oswaldo Cruz 2005; 100:107- 10. [PMID 15962107]
- Bierman HR, Byron RL Jr, Kelly KH, Gilfillan RS, White LP, Freeman NE, et al. The characteristics of thoracic duct lymph in man. J Clin Invest 1953; 32:637-49. [PMID 13069610]
- Linder E, Blomstrand R. Technic for collection of thoracic duct lymph of man. Proc Soc Exp Biol Med 1958; 97:653-7. [PMID 13518365]
- Bergstrom K, Werner B. Proteins in human thoracic duct lymph. Studies on the distribution of some proteins between lymph and blood. Acta Chir Scand 1966; 131:413-22. [PMID 5963829]
- Gabrio BW, Salomon K. Distribution of total ferritin in intestine and mesenteric lymph nodes of horses after iron feeding. Proc Soc Exp Biol Med 1950; 75:124-7. [PMID 14797757]
- Gilman T, Ivy AC. A histological study of the participation of the intestinal epithelium, the reticuloendothelial system and the lymphatics in iron absorption and transport. Gastroenterology 1947; 9:162-9.
- Mayerson HS. In: Hamilton WF, ed. Handbook of Physiology. Washington, DC, USA: American Physiological Society, 1963:1035-73.
- Everett NB, Garrett WE, Simmons BS. Lymphatics in iron absorption and transport. Am J Physiol 1954; 178:45-8. [PMID 13180709]
- Meadows R, MacWilliams P. Chylous effusions revisited. Vet Clinic Pathol 1994; 23:54-62. [PMID 12666030]
- Laine GA, Hall JT, Laine SH, Granger J. Transsinusoidal fluid dynamics in canine liver during venous hypertension. Circ Res 1979; 45:317-23. [PMID 572270]
- Vaerman JP, Heremans JF. Origin and molecular size of immunoglobulin-A in the mesenteric lymph of the dog. Immunology 1970; 18:27-38. [PMID 4983521]
- Mann JD, Mann FD, Bollman JL. Hypothprothrombinemia due to loss of intestinal lymph. Am J Physiol 1949; 158:311-4.
- Hanley CA, Johnston MG, Nelson W. Coagulation of sheep intestinal and prefemoral lymph. Lymphology 1988; 21:110-5. [PMID 3221717]
- Lindena J, Kupper W, Trautschold I. Catalytic enzyme activity concentration in thoracic duct, liver, and intestinal lymph of the dog, the rabbit, the rat and the mouse. Approach to a quantitative diagnostic enzymology, II. Communication. J Clin Chem Clin Biochem 1986; 24:19-33. [PMID 3701268]
- Flock EV, Bollman JL. Amylase and esterase in rat intestinal lymph. J Biol Chem 1950; 185:903-8. [PMID 14774438]
- Flock EV, Bollman JL. Alkaline phosphatase in the intestinal lymph of the rat. J Biol Chem 1948; 175:439-49.
- Flock EV, Bollman JL. The influence of bile on the alkaline phosphatase activity of intestinal lymph. J Biol Chem 1950; 184:523-8. [PMID 15428433]
- Dumont AE, Doubilet H, Mulholland JH. Lymphatic pathway of pancreatic secretion in man. Ann Surg 1960; 152:403-9. [PMID 13818598]
- Dumont AE, Mulholland JH. Measurement of pancreatic enzymes in human thoracic duct lymph. Gastroenterology 1960; 38:954-6. [PMID 13818601]
- Bartos V, Brzek V, Groh J. Alterations in human thoracic duct lymph in relation to the function of the pancreas. Am J Med Sci 1966; 252:31-8. [PMID 5941703]
- Singh H, Pepin J, Appert HE, Pairent FW, Howard JM. Amylase and lipase secretion in the hepatic and intestinal lymph. II. Progressive changes in enzyme levels following pancreatectomy. Arch Surg 1969; 99:80-2. [PMID 5787631]
- Rasio EA, Hampers CL, Soeldner JS, Cahill GF Jr. Diffusion of glucose, insulin, inulin, and Evans blue protein into thoracic duct lymph of man. J Clin Invest 1967; 46:903-10. [PMID 6026096]
- Rasio EA, Soeldner JS, Cahill GF. Insulin and insulin-like activity in serum and extravascular fluid. Diabetologia 1965; 1:125-7.
- Daniel PM, Henderson JR. Insulin in the thoracic duct of the rabbit. J Physiol 1966:184:36-37.
- Daniel PM, Henderson JR. Insulin in bile and other body fluids. Lancet 1967; 1; 1256-7. [PMID 4165042]
- Pepin J, Singh H, Pairent FW, Appert HE, Howard JM. A study of insulin secretion in thoracic duct lymph of the dog. Ann Surg 1970; 172:56-60. [PMID 4316644]
- Svatos A, Bartos V, Brzek V. The concentration of cholecystokinin in human lymph and serum. Arch Int Pharmacodyn Ther 1964; 149:515-20. [PMID 14191084]
- Reinhardt WO, Yoffey JM. Thoracic duct lymph and lymphocyte in the guinea pig; effects of hypoxia, fasting, evisceration and treatment with adrenaline. Am J Physiol 1956; 187:493-500. [PMID 13402912]
- Baker RD. The cellular content of chyle in relation to lymphoid tissue and fat transportation. Anat Rec 1933; 55:207-21.
- Rothkotter HJ, Hriesik C, Pabst R. More newly formed T than B lymphocytes leave the intestinal mucosa via lymphatics. Eur J Immunol 1995; 25:866-9. [PMID 7705420]
- Thielke KH, Pabst R, Rothkotter HJ. Quantification of proliferating lymphocyte subsets appearing in the intestinal lymph and blood. Clin Exp Immunol 1999; 117:277-84. [PMID 10444258]
- Lemaire LC, Van Deventer SJ, Van Lanschot JJ, Meenan J, Gouma DJ. Phenotypical characterization of cells in the thoracic duct of patients with and without systemic inflammatory response syndrome and multiple organ Failure. Scand J Immunol 1998; 47:69- 75. [PMID 9467661]
- Farstad IN, Norstein J, Brandtzaeg P. Phenotypes of B and T cells in human intestinal and mesenteric lymph. Gastroenterology 1997; 112:163-73. [PMID 8978355]
- Mallick A, Bodenham AR. Disorders of the lymph circulation: their relevance to anaesthesia and intensive care. Br J Anaesth 2003; 91:265-72. [PMID 12878626]
- Rusznyak I, Foldi M, Szabo G. In: Youlten L, ed. Lymphatics and Lymph Circulation Physiology and Pathology. London: Pergamon Press, 1967.
- Courtice FC, Simmonds WJ, Steinbeck AW. Some investigations of lymph from a thoracic duct fistula in man. Aust J Exp Biol Med Sci 1951; 29:201-10. [PMID 14869281]
- Morris B. The hepatic and intestinal contributions to the thoracic duct lymph. Q J Exp Physiol Cogn Med Sci 1956; 41:318-25. [PMID 13485348]
- Gabler WL, Fosdick LS. Flow rate and composition of thoracic duct lymph with and without cisterna chyle ligation. Proc Soc Exp Biol Med 1964; 115:915-8. [PMID 14166607]
- Cain JC, Grindlay JH, Bollman JL, Flock EV, Mann FC. Lymph from liver and thoracic duct: an experimental study. Surg Gynecol Obstet 1947; 85:559.
- Nix JT, Mann FC, Bollman JL, Grindlay JH, Flock EV. Alterations of protein constituents of lymph by specific injury to the liver. Am J Physiol 1951; 164:119-22. [PMID 14810910]
- Mobley WP, Kintner K, Witte CL, Witte MH. Contribution of the liver to thoracic duct lymph flow in a motionless subject. Lymphology 1989; 22:81-4. [PMID 2770355]
- Shannon AD, Lascelles AK. The intestinal and hepatic contributions to the flow and composition of thoracic duct lymph in young milk-fed calves. Q J Exp Physiol Cogn Med Sci 1968; 53:194-205. [PMID 5185571]
- Felinski L, Garton GA, Lough AK, Phillipson AT. Lipids of sheep lymph. Transport from the intestine. Biochem J 1964; 90:154-60. [PMID 5832286]
- Gashev AA, Davis MJ, Zawieja DC. Inhibition of the active lymph pump by flow in rat mesenteric lymphatics and thoracic duct. J Physiol 2002; 540:1023-37. [PMID 11986387]
- Davidson MT, Deitch EA, Lu Q, Osband A, Feketeova E, Nemeth ZH, et al. A study of the biologic activity of trauma-hemorrhagic shock mesenteric lymph over time and the relative role of cytokines. Surgery 2004; 136:32-41. [PMID 15232537]
- Gonzalez RJ, Moore EE, Ciesla DJ, Nieto JR, Johnson JL, Silliman CC. Post-hemorrhagic shock mesenteric lymph activates human pulmonary microvascular endothelium for in vitro neutrophilmediated injury: the role of intercellular adhesion molecule-1. J Trauma 2003; 54:219-23. [PMID 12579043]
- Moore EE. Mesenteric lymph: the critical bridge between dysfunctional gut and multiple organ failure. Shock 1998; 10:415-6. [PMID 9872680]
- Magnotti LJ, Xu DZ, Lu Q, Deitch EA. Gutderived mesenteric lymph: a link between burn and lung injury. Arch Surg 1999; 134:1333-40. [PMID 10593331]
- Yatani A, Xu DZ, Kim SJ, Vatner SF, Deitch EA. Mesenteric lymph from rats with thermal injury prolongs the action potential and increases Ca2+ transient in rat ventricular myocytes. Shock 2003; 20:458-64. [PMID 14560111]
- Anup R, Balasubramanian KA. Surgical stress and the gastrointestinal tract. J Surg Res 2000; 92:291-300. [PMID 10896836]
- Anup R, Susama P, Balasubramanian KA. Role of xanthine oxidase in small bowel mucosal dysfunction after surgical stress. Br J Surg 2000; 87:1094-101. [PMID 10931057]
- Parikh AA, Moon MR, Pritts TA, Fischer JE, Szabo C, Hasselgren PO, Salzman AL. IL-1beta induction of NF-kappaB activation in human intestinal epithelial cells is independent of oxyradical signaling. Shock 2000; 13:8-13. [PMID 10638662]
- Wang JF, Gao YQ, Lippton H, Hyman A, Spitzer JJ. The roles of nitric oxide and hydrogen peroxide production in lipopolysaccharide-induced intestinal damage. Shock 1994; 2:185-91. [PMID 7743348]
- Nakamura M, Motoyama S, Saito S, Minamiya Y, Saito R, Ogawa J. Hydrogen peroxide derived from intestine through the mesenteric lymph induces lung edema after surgical stress. Shock 2004; 21:160-4. [PMID 14752290]
- Deitch EA, Shi HP, Lu Q, Feketeova E, Xu DZ. Serine proteases are involved in the pathogenesis of trauma-hemorrhagic shock-induced gut and lung injury. Shock 2003; 19:452-6. [PMID 12744489]
- Osband AJ, Deitch EA, Lu Q, Zaets S, Dayal S, Lukose B, Xu DZ. The role of oxidant-mediated pathways in the cytotoxicity of endothelial cells exposed to mesenteric lymph from rats subjected to trauma-hemorrhagic shock. Shock 2003; 20:269-73. [PMID 12923500]
- Gonzalez RJ, Moore EE, Ciesla DJ, Meng X, Biffl WL, Silliman CC. Post-hemorrhagic shock mesenteric lymph lipids prime neutrophils for enhanced cytotoxicity via phospholipase A2. Shock 2001; 16:218-22. [PMID 11531024]
- Gonzalez RJ, Moore EE, Ciesla DJ, Biffl WL, Offner PJ, Silliman CC. Phospholipase A(2). Derived neutral lipids from posthemorrhagic shock mesenteric lymph prime the neutrophil oxidative burst. Surgery 2001; 130:198-203. [PMID 11490349]
- Davidson MT, Deitch EA, Lu Q, Hasko G, Abungu B, Nemeth ZH, et al. Trauma-hemorrhagic shock mesenteric lymph induces endothelial apoptosis that involves both caspase-dependent and caspaseindependent mechanisms. Ann Surg 2004; 240:123-31. [PMID 15213628]
- Gonzalez RJ, Moore EE, Biffl WL, Ciesla DJ, Silliman CC. The lipid fraction of post-hemorrhagic shock mesenteric lymph (PHSML) inhibits neutrophil apoptosis and enhances cytotoxic potential. Shock 2000; 14:404-8. [PMID 11028564]
- Sarin EL, Moore EE, Moore JB, Masuno T, Moore JL, Banerjee A, Silliman CC. Systemic neutrophil priming by lipid mediators in post-shock mesenteric lymph exists across species. J Trauma 2004; 57:950-4. [PMID 15580016]
- Dayal SD, Hauser CJ, Feketeova E, Fekete Z, Adams JM, Lu Q, et al. Shock mesenteric lymphinduced rat polymorphonuclear neutrophil activation and endothelial cell injury is mediated by aqueous factors. J Trauma 2002; 52:1048-55. [PMID 12045629]
- Kaiser VL, Sifri ZC, Dikdan GS, Berezina T, Zaets S, Lu Q, et al. Trauma-hemorrhagic shock mesenteric lymph from the rat contains a modified form of albumin that is implicated in endothelial cell toxicity. Shock 2005; 23:417-25. [PMID 15834307]
- Osband AJ, Sifri ZC, Wang L, Cohen D, Hauser CJ, Mohr AM, et al. Small volume albumin administration protects against hemorrhagic shockinduced bone marrow dysfunction. J Trauma 2004; 56:279-83. [PMID 14960968]
- Adams CA Jr, Xu DZ, Lu Q, Deitch EA. Factors larger than 100 kD in post-hemorrhagic shock mesenteric lymph are toxic for endothelial cells. Surgery 2001; 129:351-63. [PMID 11231464]
- Deitch EA, Adams CA, Lu Q, Xu DZ. Mesenteric lymph from rats subjected to trauma-hemorrhagic shock are injurious to rat pulmonary microvascular endothelial cells as well as human umbilical vein endothelial cells. Shock 2001; 16:290-3. [PMID 11580112]
- Beecher HK, McCarrell JD, Evans EI. A study of the “shock-delaying” action of the barbiturates: with a consideration of the failure of oxygen-rich atmospheres to delay the onset of experimental shock during anesthesia. Ann Surg 1942; 116:658.
- Seeley SF, Essex HE, Mann FC. Comparative studies on traumatic shock under ether and under sodium amytal anesthesia: an experimental research. Ann Surg 1936; 104:332.
- Hungerford GF, Reinhardt WO. Comparison of effects of sodium pentobarbital or ether-induced anesthesia on rate of flow and cell content of rat thoracic duct lymph. Am J Physiol 1950; 160:9-14. [PMID 15403631]
- Evans WE, Darin JC. Effect of enterectomy in endotoxin shock. Surgery 1966; 60:1026-9. [PMID 5333170]
- Gergely M, Horpacsy G, Barankay T, Petri G. Effects of small intestinal resection or exclusion in haemorrhagic shock. Acta Physiol Acad Sci Hung 1970; 37:301-11. [PMID 5497617]
- Gergely M, Nagy S. Effect of exclusion of small intestine in haemorrhagic shock. Acta Physiol Acad Sci Hung 1969; 35:93-7. [PMID 5792216]
- Gergely M. The effect of intestinal resection and exclusion on survival after experimental hemorrhagic shock. Orv Hetil 1971; 112:855-7. [PMID 5089046]
- Chang TW. Improvement of survival from hemorrhagic shock by enterectomy in rats: finding to implicate the role of the gut for irreversibility of hemorrhagic shock. J Trauma 1997; 42:223-30. [PMID 9042872]
- Dumont AE, Weissmann G. Lymphatic transport of beta-glucuronidase during haemorrhagic shock. Nature 1964; 201:1231-2. [PMID 14151384]
- Barankay T, Horpacsy G, Nagy S, Petri G. Changes in the level of lysosomal enzymes in plasma and lymph in hemorrhagic shock. Med Exp Int J Exp Med 1969; 19:267-71. [PMID 5396052]
- Glenn TM, Lefer AM. Protective effect of thoracic lymph diversion in hemorrhagic shock. Am J Physiol 1970; 219:1305-10. [PMID 5022386]
- Upperman JS, Deitch EA, Guo W, Lu Q, Xu D. Post-hemorrhagic shock mesenteric lymph is cytotoxic to endothelial cells and activates neutrophils. Shock 1998; 10:407-14. [PMID 9872679]
- Dayal SD, Hasko G, Lu Q, Xu DZ, Caruso JM, Sambol JT, Deitch EA. Trauma/hemorrhagic shock mesenteric lymph upregulates adhesion molecule expression and IL-6 production in human umbilical vein endothelial cells. Shock 2002; 17:491-5. [PMID 12069186]
- Caruso JM, Feketeova E, Dayal SD, Hauser CJ, Deitch EA. Factors in intestinal lymph after shock increase neutrophil adhesion molecule expression and pulmonary leukosequestration. J Trauma 2003; 55:727- 33. [PMID 14566130]
- Lu Q, Xu DZ, Davidson MT, Hasko G, Deitch EA. Hemorrhagic shock induces endothelial cell apoptosis, which is mediated by factors contained in mesenteric lymph. Crit Care Med 2004; 32:2464-70. [PMID 15599152]
- Xu DZ, Lu Q, Adams CA, Issekutz AC, Deitch EA. Trauma-hemorrhagic shock-induced up-regulation of endothelial cell adhesion molecules is blunted by mesenteric lymph duct ligation. Crit Care Med 2004; 32:760-5. [PMID 15090959]
- Zaets SB, Berezina TL, Morgan C, Kamiyama M, Spolarics Z, Xu DZ, et al. Effect of traumahemorrhagic shock on red blood cell deformability and shape. Shock 2003; 19:268-73. [PMID 12630528]
- Deitch EA, Forsythe R, Anjaria D, Livingston DH, Lu Q, Xu DZ, Redl H. The role of lymph factors in lung injury, bone marrow suppression, and endothelial cell dysfunction in a primate model of traumahemorrhagic shock. Shock 2004; 22:221-8. [PMID 15316391]
- Sambol JT, White J, Horton JW, Deitch EA. Burninduced impairment of cardiac contractile function is due to gut-derived factors transported in mesenteric lymph. Shock 2002; 18:272-6. [PMID 12353930]
- Takala J. Determinants of splanchnic blood flow. Br J Anaesth 1996; 77:50-8. [PMID 8703630]
- Wattanasirichaigoon S, Menconi MJ, Delude RL, Fink MP. Effect of mesenteric ischemia and reperfusion or hemorrhagic shock on intestinal mucosal permeability and ATP content in rats. Shock 1999; 12:127-133. [PMID 10446893]
- Chiu CJ, McArdle AH, Brown R, Scott HJ, Gurd FN. Intestinal mucosal lesion in low-flow states. I. A morphological, hemodynamic, and metabolic reappraisal. Arch Surg 1970; 101:478-83. [PMID 5457245]
- Zimmerman B, Granger D. Oxygen free radicals and the gastrointestinal tract: Role in ischemiareperfusion injury. Hepatogastroenterology 1994; 41:337-42. [PMID 7959568]
- Salzman AL, Menconi MJ, Unno N, Ezzell RM, Casey DM, Gonzalez PK, Fink MP. Nitric oxide dilates tight junctions and depletes ATP in cultured Caco- 2BBe intestinal epithelial monolayers. Am J Physiol 1995; 268:G361-73. [PMID 7864133]
- Taylor C, Dzus A, Colgan S. Autocrine regulation of epithelial permeability by hypoxia: role for polarized release of tumor necrosis factor alpha. Gastroenterology 1998; 114:657-68. [PMID 9516386]
- Austen W Jr, Kyridkides C, Favuzza J, Wang Y, Kobniz L, Moore FD Jr, et al. Intestinal ischemiareperfusion injury is mediated by the membrane attack complex. Surgery 1999; 126:343-8. [PMID 10455904]
- Wolochow H, Hildebrand GJ, Lamanna C. Translocation of microorganisms across the intestinal wall of the rat: effect of microbial size and concentration. J Infect Dis 1966; 116:523-8 [PMID 4959185]
- Deitch EA. Bacterial translocation of the gut flora. J Trauma 1990; 30:S184-9. [PMID 2254980]
- Kong SE, Blennerhassett LR, Heel KA, McCauley RD, Hall JC. Ischaemia-reperfusion injury to the intestine. Aust N Z J Surg 1998; 68:554-61. [PMID 9715130]
- Carrico CJ, Meakins JL, Marshall JC, Fry D, Maier RV. Multiple-organ-failure syndrome. Arch Surg 1986; 121:196-208. [PMID 3484944]
- Marshall JC, Christou NV, Meakins JL. The gastrointestinal tract. The "undrained abscess" of multiple organ failure. Ann Surg 1993; 218:111-9. [PMID 8342990]
- Kozar RA, Holcomb JB, Hassoun HT, Macaitis J, DeSoignie R, Moore FA. Superior mesenteric artery occlusion models shock-induced gut ischemiareperfusion. J Surg Res 2004; 116:145-50. [PMID 14732361]
- Cavriani G, Domingos HV, Soares AL, Trezena AG, Ligeiro-Oliveira AP, Oliveira-Filho RM, et al. Lymphatic system as a path underlying the spread of lung and gut injury after intestinal ischemia/reperfusion in rats. Shock 2005; 23:330-6. [PMID 15803056]
- Longhurst JC, Benham RA, Rendig SV. Increased concentration of leukotriene B4 but not thromboxane B2 in intestinal lymph of cats during brief ischemia. Am J Physiol 1992; 262:H1482-5. [PMID 1317130]
- Brzek V, Bartos V. Therapeutic effect of the prolonged thoracic duct lymph fistula in patients with acute pancreatitis. Digestion 1969; 2:43-50. [PMID 5776466]
- Kiriakou K, Andreadis P, Toussis D, Danielides B, Tountas C. The effect of the intestinal factor on the mortality of experimental pancreatitis. Surg Gynecol Obstet 1969; 128:340-7. [PMID 5304993]
- Berezina TL, Zaets SB, Mole DJ, Spolarics Z, Deitch EA, Machiedo GW. Mesenteric lymph duct ligation decreases red blood cell alterations caused by acute pancreatitis. Am J Surg 2005; 190:800-4. [PMID 16226961]
- Baumgart DC, Dignass AU. Intestinal barrier function. Curr Opin Clin Nutr Care 2002; 5:685-94. [PMID 12394645]
- Schmid-Schonbein GW, Hugli TE. A new hypothesis for microvascular inflammation in shock and multiorgan failure: self-digestion by pancreatic enzymes. Microcirculation 2005; 12:71-82. [PMID 15804975]
- Deitch EA, Shi HP, Feketeova E, Hauser CJ, Xu DZ. Hypertonic saline resuscitation limits neutrophil activation after trauma-hemorrhagic shock. Shock 2003; 19:328-33. [PMID 12688543]
- Gonzalez RJ, Moore EE, Ciesla DJ, Neto JR, Biffl WL, Silliman CC. Hyperosmolarity abrogates neutrophil cytotoxicity provoked by post-shock mesenteric lymph. Shock 2002; 18:29-32. [PMID 12095130]
- Zallen G, Moore EE, Tamura DY, Johnson JL, Biffl WL, Silliman CC, et al. Hypertonic saline resuscitation abrogates neutrophil priming by mesenteric lymph. J Trauma 2000; 48:45-8. [PMID 10647564]
- Sims CA, Wattanasirichaigoon S, Menconi MJ, Ajami AM, Fink MP. Ringer's ethyl pyruvate solution ameliorates ischemia/reperfusion-induced intestinal mucosal injury in rats. Crit Care Med 2001; 29:1513-8. [PMID 11505117]
- Osband AJ, Deitch EA, Hauser CJ, Lu Q, Zaets S, Berezina T, et al. Albumin protects against gut-induced lung injury in vitro and in vivo. Ann Surg 2004; 240:331-9. [PMID 15273559]
- Cicalese L, Subbotin V, Rastellini C, Stanko RT, Rao AS, Fung JJ. Preservation injury and acute rejection of rat intestinal grafts: protection afforded by pyruvate. J Gastrointest Surg 1999; 3:549-54. [PMID 10482714]
- Schleiffer R, Raul F. Prophylactic administration of L-arginine improves the intestinal barrier function after mesenteric ischaemia. Gut 1996; 39:194-8. [PMID 8991856]
- Lee C, Xu DZ, Feketeova E, Kannan KB, Yun JK, Deitch EA, et al. Attenuation of shock-induced acute lung injury by sphingosine kinase inhibition. J Trauma 2004; 57:955-60. [PMID 15580017]
- Mitsuoka H, Kistler EB, Schmid-Schonbein GW. Protease inhibition in the intestinal lumen: attenuation of systemic inflammation and early indicators of multiple organ failure in shock. Shock 2002; 17:205-9. [PMID 11900339]
- Ito K, Ozasa H, Horikawa S. Edaravone protects against lung injury induced by intestinal ischemia/reperfusion in rat. Free Radic Biol Med 2005; 38:369-74. [PMID 15629865]
- Hassoun HT, Fischer UM, Attuwaybi BO, Moore FA, Safi HJ, Allen SJ, Cox CS Jr. Regional hypothermia reduces mucosal NF-kappaB and PMN priming via gut lymph during canine mesenteric ischemia/reperfusion. J Surg Res 2003; 115:121-6. [PMID 14572782]
- Glenn TM, Herlihy BL, Ferguson WW, Lefer AM. Protective effect of pancreatic duct ligation in splanchnic ischemia shock. Am J Physiol 1972; 222:1278-84. [PMID 5022386]
- Lefer AM, Glenn TM. Role of the pancreas in the pathogenesis of circulatory shock. Adv Exp Med Biol 1971; 23:311-35. [PMID 5006110]
- Adams CA Jr, Hauser CJ, Adams JM, Fekete Z, Xu DZ, Sambol JT, Deitch EA. Trauma-hemorrhageinduced neutrophil priming is prevented by mesenteric lymph duct ligation. Shock 2002; 18:513-7. [PMID 12462558]
- Deitch EA, Adams C, Lu Q, Xu DZ. A time course study of the protective effect of mesenteric lymph duct ligation on hemorrhagic shock-induced pulmonary injury and the toxic effects of lymph from shocked rats on endothelial cell monolayer permeability. Surgery 2001; 129:39-47. [PMID 11150032]
- Adams CA Jr, Sambol JT, Xu DZ, Lu Q, Granger DN, Deitch EA, et al. Hemorrhagic shock induced upregulation of P-selectin expression is mediated by factors in mesenteric lymph and blunted by mesenteric lymph duct interruption. J Trauma 2001; 51:625-31. [PMID 11586150]
- Adams JM, Hauser CJ, Adams CA Jr, Xu DZ, Livingston DH, Deitch EA, et al. Entry of gut lymph into the circulation primes rat neutrophil respiratory burst in hemorrhagic shock. Crit Care Med 2001; 29:2194-8. [PMID 11700422]
- Zaets SB, Berezina TL, Caruso J, Xu DZ, Deitch EA, Machiedo GW. Mesenteric lymph duct ligation prevents shock-induced RBC deformability and shape changes. J Surg Res 2003; 109:51-6. [PMID 12591235]
- Anjaria DJ, Rameshwar P, Deitch EA, Xu DZ, Adams CA, Forsythe RM, et al. Hematopoietic failure after hemorrhagic shock is mediated partially through mesenteric lymph. Crit Care Med 2001; 29:1780-5. [PMID 11546985]
- Zallen G, Moore EE, Johnson JL, Tamura DY, Ciesla DJ, Silliman CC. Posthemorrhagic shock mesenteric lymph primes circulating neutrophils and provokes lung injury. J Surg Res 1999; 83:83-8. [PMID 10329099]
- Cox CS Jr, Fischer UM, Allen SJ, Laine GA. Lymphatic diversion prevents myocardial edema following mesenteric ischemia/reperfusion. Microcirculation 2004; 11:1-8. [PMID 15280094]
- Chen ZB, Zheng SS, Yuan G, Ding CY, Zhang Y, Zhao XH, et al. Effects of intestinal lymph on expression of neutrophil adhesion factors and lung injury after trauma-induced shock. World J Gastroenterol 2004; 10:3221-4. [PMID 15457581]
- Smith RO. Lymphatic contractility. A possible intrinsic mechanism of lymphatic vessels for the transport of lymph. J Exp Med 1949; 90:497-509.
- Szwed JJ, Maxwell DR, Elliott R, Redlich LR. Diuretics and small intestinal lymph flow in the dog. J Pharmacol Exp Ther 1977; 200:88-94. [PMID 833766]
- Mohr D, Umeda Y, Redgrave TG, Stocker R. Antioxidant defenses in rat intestine and mesenteric lymph. Redox Rep 1999; 4:79-87. [PMID 10496410]
- Kentner R, Safar P, Behringer W, Wu X, Kagan VE, Tyurina YY, et al. Early antioxidant therapy with Tempol during hemorrhagic shock increases survival in rats. J Trauma 2002; 53:968-77. [PMID 12435951]
- Johnson G 3rd, Lefer AM. Protective effects of a novel 21-aminosteroid during splanchnic artery occlusion shock. Circ Shock 1990; 30:155-64. [PMID 2311204]
- Windsor AC, Kanwar S, Li AG, Barnes E, Guthrie JA, Spark JI, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 1998; 42:431-5. [PMID 9577354]
- McClave SA, Greene LM, Snider HL, Makk LJ, Cheadle WG, Owens NA, et al. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enteral Nutr 1997; 21:14-20. [PMID 9002079]
- Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997; 84:1665- 9. [PMID 9448611]
- Pupelis G, Austrums E, Jansone A, Sprucs R, Wehbi H. Randomised trial of safety and efficacy of postoperative enteral feeding in patients with severe pancreatitis: preliminary report. Eur J Surg 2000; 166:383-7. [PMID 10881949]
- Mackenzie SL, Zygun DA, Whitmore BL, Doig CJ, Hameed SM. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. JPEN J Parenter Enteral Nutr 2005; 29:74-80. [PMID 15772383]
- Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004; 328:1407. [PMID 15175229]
- Borgstrom B, Laurell CB. Studies of lymph and lymph-proteins during absorption of fat and saline by rats. Acta Physiol Scand 1953; 29:264-80. [PMID 13114001]
- Powell JJ, Murchison JT, Fearon KC, Ross JA, Siriwardena AK. Randomized controlled trial of the effect of early enteral nutrition on markers of the inflammatory response in predicted severe acute pancreatitis. Br J Surg 2000; 87:1375-81. [PMID 11044164]
- Benoit JN. Relationships between lymphatic pump flow and total lymph flow in the small intestine. Am J Physiol 1991; 261:H1970-8. [PMID 1750545]
- Granger DN, Mortillaro NA, Taylor AE. Interactions of intestinal lymph flow and secretion. Am J Physiol 1977; 232:E13-8. [PMID 835698]
- Marts BC, Naunheim KS, Fiore AC, Pennington DG. Conservative versus surgical management of chylothorax. Am J Surg 1992; 164:532-4. [PMID 1443383]
- Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg 1998; 85:1147-9. [PMID 9718017]
- Pabst TS 3rd, McIntyre KE Jr, Schilling JD, Hunter GC, Bernhard VM. Management of chyloperitoneum after abdominal aortic surgery. Am J Surg 1993; 166:194-8. [PMID 8352415]
- Kieft H, Roos AN, van Drunen JD, Bindels AJ, Bindels JG, Hofman Z. Clinical outcome of immunonutrition in a heterogeneous intensive care population. Intensive Care Med 2005; 31:524-32. [PMID 15703894]
- Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J, Champoux J, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Crit Care Med 2003; 31:2444-9. [PMID 14530749]
- Chuntrasakul C, Siltham S, Sarasombath S, Sittapairochana C, Leowattana W, Chockvivatanavanit S, Bunnak A. Comparison of a immunonutrition formula enriched arginine, glutamine and omega-3 fatty acid, with a currently high-enriched enteral nutrition for trauma patients. J Med Assoc Thai 2003; 86:552-61. [PMID 12924804]
- von der Weid PY, Zhao J, Van Helden DF. Nitric oxide decreases pacemaker activity in lymphatic vessels of guinea pig mesentery. Am J Physiol Heart Circ Physiol 2001; 280:H2707-16. [PMID 11356627]
- Usovich AK, Makhmudov ZA, Borziak EI. Is there an intestinal lymphatic trunk in man? Arkh Anat Gistol Embriol 1981; 80:31-4. [PMID 7259541]
- Frank BW, Kern F Jr. Intestinal and liver lymph and lymphatics. Gastroenterology 1968; 55:408-22. [PMID 4877419]
- Sambol JT, Xu DZ, Adams CA, Magnotti LJ, Deitch EA. Mesenteric lymph duct ligation provides long term protection against hemorrhagic shockinduced lung injury. Shock 2000; 14:416-9. [PMID 11028566]
- Tsuchiya H, Nagashima K, Nemoto T. Blockage of mesenteric lymphatic flow in rats. Pediatr Surg Int 1997; 12:360-3. [PMID 9244099]
- Uner A, Weinberg AM, Nautrup CP, Kassianoff I, Ludemann W, Schier F, et al. Spontaneous reanastomosis between lymphatic vessels following syngeneic transplantation of the small intestine in the rat. Surg Radiol Anat 2001; 23:383-7. [PMID 11963620]
- Goott B, Lillehei C, Miller FA. Mesenteric lymphatic regeneration after autografts of small bowel in dogs. Surgery 1960; 48:571-5. [PMID 13707085]
- Larson DL, Bond TP, Rodin AE, Coers CR, Lewis SR. Clinical and experminental obstruction of the thoracic duct. Surgery 1996; 60:35.
- Fish JC, McNeel L, Holaday WJ. Lymphatic obstruction in the pathogenesis of intestinal mucosal atrophy. Ann Surg 1969; 169:316-25. [PMID 5380857]
- Wemyss-Holden SA, Launois B, Maddern GJ. Management of thoracic duct injuries after oesophagectomy. Br J Surg 2001; 88:1442-8. [PMID 1163738]
- Blalock A, Robinson CS, Cunningham RS, Gray ME. Experimental studies on lymphatic blockage. Arch Surg 1937; 34:1049-71.
- Dumont AE, Martelli AB, Mulholland JH. Alterations in tissue reactivity of thoracic duct lymph produced by retention of excess pancreatic secretion. Proc Soc Exp Biol Med 1996; 121:1-5. [PMID 5902932]
- Papp M, Pappne NE, Feuer I, Fodor I. Effects of obstruction of lymphatic circulation on experimental acute pancreatitis. Orv Hetil 1957; 98:580-2. [PMID 13452533]
- Papp M, Nemeth E, Feuer I, Fodor I. Effect of an impairment of lymph flow on experimental acute pancreatitis. Acta Med Acad Sci Hung 1958; 11:203-8. [PMID 13508028]
- Bartos V, Brzek V. Significance of thoracic duct drainage in clinical medicine. Chirurg 1973; 44:110-4. [PMID 4697272]
- Dugernier T, Reynaert MS, Deby-Dupont G, Roeseler JJ, Carlier M, Squifflet JP, et al. Prospective evaluation of thoracic-duct drainage in the treatment of respiratory failure complicating severe acute pancreatitis. Intensive Care Med 1989; 15:372-8. [PMID 2553789]
- Bondarev VI, Golovnia PF, Sviridov NV. Substantiation of optimal combination of external drainage of the thoracic duct, lymphosorption and hemosorption in the complex treatment of patients with destructive pancreatitis. Klin Khir 1989; 11:7-9. [PMID 2625872]
- Dugernier TL, Laterre PF, Wittebole X, Roeseler J, Latinne D, Reynaert MS, Pugin J. Compartmentalization of the inflammatory response during acute pancreatitis: correlation with local and systemic complications. Am J Respir Crit Care Med 2003; 168:148-57. [PMID 12851244]
- Raraty MG, Neoptolemos JP. Compartments that cause the real damage in severe acute pancreatitis. Am J Respir Crit Care Med 2003; 168:141-2. [PMID 12851239]
- Jeffries GH, Chapman A, Sleisenger MH. Low fat diet in intestinal lymphangiectasia. Its effect on albumin metabolism. N Engl J Med 1964; 270:761-6. [PMID 14107315]
- Simmonds WJ. The effect of fluids, electrolytes and food intake on thoracic duct lymph flow in unanaesthetized rats. Aust J Exp Biol Med Sci 1954; 32:285-99. [PMID 13208470]
- Shrewsbury MM Jr, Reinhardt WO. Comparative metabolic effects of ingestion of water or 1 per cent sodium chloride solution in the rat with a thoracic duct lymph fistula. Am J Physiol 1952; 168:366-74. [PMID 14903151]
- Granger DN. Intestinal microcirculation and transmucosal fluid transport. Am J Physiol 1981; 240:G343-9. [PMID 7015880]
- Levine SE, Granger DN, Brace RA, Taylor AE. Effect of hyperosmolality on vascular resistance and lymph flow in the cat ileum. Am J Physiol 1978; 234:H14-20. [PMID 637909]
- Lee JS. Intestinal transudation, secretion, and lymph flow during volume expansion in the rat. Am J Physiol 1983; 244:G668-74. [PMID 6859275]
- Drake RE, Abbott RD. Effect of increased neck vein pressure on intestinal lymphatic pressure in awake sheep. Am J Physiol 1992; 262:R892-4. [PMID 1590483]
- Granger DN, Mortillaro NA, Perry MA, Kvietys PR. Autoregulation of intestinal capillary filtration rate. Am J Physiol 1982; 243:G475-83. [PMID 7149030]
- Moore-Olufemi SD, Xue H, Allen SJ, Moore FA, Stewart RH, Laine GA, Cox CS Jr. Effects of primary and secondary intra-abdominal hypertension on mesenteric lymph flow: Implications for the abdominal compartment syndrome. Shock 2005; 23:571-5. [PMID 15897812]
- Elk JR, Laine GA. Pressure within the thoracic duct modulates lymph composition. Microvasc Res 1990; 39:315-21. [PMID 2362555]
- Mortillaro NA, Taylor AE. Interaction of capillary and tissue forces in the cat small intestine. Circ Res 1976; 39:348-58. [PMID 954164]
- Granger DN, Kvietys PR, Mortillaro NA, Taylor AE. Effect of luminal distension on intestinal transcapillary fluid exchange. Am J Physiol 1980; 239:G516-23. [PMID 7446745]
- Ackerman NB. The influences of mechanical factors on intestinal lymph flow and their relationship to operations for carcinoma of the intestine. Surg Gynecol Obstet 1974; 138:677-82. [PMID 4823369]
- Ackerman NB. The influences of changes in temperature on intestinal lymph flow and relationship to operations for carcinoma of the intestine. Surg Gynecol Obstet 1975; 140:885-8. [PMID 1129679]
- Groth CG, Loefstroem B, Werner B. Oxygen tension of thoracic duct lymph in man. Acta Chir Scand 1965; 129:586-90. [PMID 14337931]
- Quillen EW, Granger DN, Taylor AE. Effects of arginine vasopressin on capillary filtration in the cat ileum. Gastroenterology 1977; 73:1290-5. [PMID 913970]
- Qin X, Shen H, Liu M, Yang Q, Zheng S, Sabo M, et al. GLP-1 reduces intestinal lymph flow, triglyceride absorption, and apolipoprotein production in rats. Am J Physiol Gastrointest Liver Physiol 2005; 288:G943-9. [PMID 15677555]
- Lee JS. Motility, lymphatic contractility, and distention pressure in intestinal absorption. Am J Physiol 1965; 208:621-7. [PMID 14274788]
- Lee JS. Relationship between intestinal motility, tone, water absorption and lymph flow in the rat. J Physiol 1983; 345:489-99. [PMID 6141290]
- Granger DN, Cross R, Barrowman JA. Effects of various secretagogues and human carcinoid serum on lymph flow in the cat ileum. Gastroenterology 1982; 83:896-901. [PMID 7106519]
- Al-Zubairy SA, Al-Jazairi AS. Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother 2003; 37:679-82. [PMID 12708946]
- Barrowman JA, Turner SG. Cholecystokinin and glucagon are intestinal lymphagogues in the rat [Proceedings]. J Physiol 1978; 278:20P-21P. [PMID 671287]
- Turner SG, Barrowman JA. The effects of cholecystokinin and cholecystokinin-octapeptide on intestinal lymph flow in the rat. Can J Physiol Pharmacol 1977; 55:1393-6. [PMID 597788]
- Barrowman JA, Kwan P, Mousseau C, Turner SG. The effect of glucagon on intestinal lymph flow in rats. Can J Physiol Pharmacol 1978; 56:531-2. [PMID 667731]
- Lawrence JA, Bryant D, Roberts KB, Barrowman JA. Effect of secretin on intestinal lymph flow and composition in the rat. Q J Exp Physiol 1981; 66:297- 305. [PMID 6910730]
- Mortillaro NA, Granger DN, Kvietys PR, Rutili G, Taylor AE. Effects of histamine and histamine antagonists on intestinal capillary permeability. Am J Physiol 1981; 240:G381-6. [PMID 7235025]
- Granger DN, Shackleford JS, Taylor AE. PGE1- induced intestinal secretion: mechanism of enhanced transmucosal protein efflux. Am J Physiol 1979; 236:E788-96. [PMID 443432]
- Kolmen SN, Eichler AC, Smith JH. The effects of chronic lymphatic diversion on hypertensive and uremic states in dogs. Tex Rep Biol Med 1963; 21:357- 68. [PMID 14061531]
- Leandoer L, Lewis DH. The effect of Lnorepinephrine on lymph flow in man. Ann Surg 1970; 171:257-60. [PMID 5413461]
- Kolmen SN, Daily LJ Jr, Traber DL. Autonomic involvement in the lymphatic delivery of fibrinogen. Am J Physiol 1965; 209:1123-7. [PMID 5847398]
- Pearl GJ, Trank JW, Gurd FN, Hampson LG. Lymph flow patterns under the influence of pressor amines, ganglionic blocking agents, and haemorrhagic shock. Surg Forum 1963; 14:14-6. [PMID 14064491]
- Baraona E, Lieber CS. Intestinal lymph formation and fat absorption: stimulation by acute ethanol administration and inhibition by chronic ethanol administration and inhibition by chronic ethanol feeding. Gastroenterology 1975; 68:495-502. [PMID 803464]
- Witte MH, Witte CL, Dumont AE. Estimated net transcapillary water and protein flux in the liver and intestine of patients with portal hypertension from hepatic cirrhosis. Gastroenterology 1981; 80:265-72. [PMID 7450417]
- Granger DN, Barrowman JA. Microcirculation of the alimentary tract. II. Pathophysiology of edema. Gastroenterology 1983; 84:1035-49. [PMID 6339310]
- Granger DN, Sennett M, McElearney P, Taylor AE. Effect of local arterial hypotension on cat intestinal capillary permeability. Gastroenterology 1980; 79:474-80. [PMID 7429108]
- Benoit JN. Effects of alpha-adrenergic stimuli on mesenteric collecting lymphatics in the rate. Am J Physiol 1997; 273:R331-6. [PMID 9249568]
- McHale NG, Roddie IC, Thornbury KD. Noradrenaline as an excitatory neutrotransmitter in bovine mesenteric lymphatics [Proceedings]. J Physiol 1979; 295:94P. [PMID 230344]
- McLean PG, Coupar IM, Molenaar P. A comparative study of functional 5-HT4 receptors in human colon, rat oesophagus and rat ileum. Br J Pharmacol 1995; 115:47-56. [PMID 7647983]
- McHale NG, Thornbury KD, Hollywood MA. 5- HT inhibits spontaneous contractility of isolated sheep mesenteric lymphatics via activation of 5-HT(4) receptors. Microvasc Res 2000; 60:261-8. [PMID 11078642]
- Tuladhar BR, Costall B, Naylor RJ. Pharmacological characterization of the 5- hydroxytryptamine receptor mediating relaxation in the rat isolated ileum. Br J Pharmacol 1996; 119:303-10. [PMID 8886413]
- Ohhashi T. Mechanisms for regulating tone in lymphatic vessels. Biochem Pharmacol 1993; 45:1941- 6. [PMID 8512579]
- Tuladhar BR, Womack MD, Naylor RJ. Pharmacological characterization of the 5-HT receptormediated contraction in the mouse isolated ileum. Br J Pharmacol 2000; 131:1716-22. [PMID 11139451]
- Ohhashi T, Azuma T. Variegated effects of prostaglandins on spontaneous activity in bovine mesenteric lymphatics. Microvasc Res 1984; 27:71-80. [PMID 6143241]
- Johnston MG, Gordon JL. Regulation of lymphatic contractility by arachidonate metabolites. Nature 1981; 293:294-7. [PMID 7196995]
- Allen JM, Burke EP, Johnston MG, McHale NG. The inhibitory effect of aspirin on lymphatic contractility. Br J Pharmacol 1984; 82:509-14. [PMID 6733366]
- Yokoyama S, Ohhashi T. Effects of acetylcholine on spontaneous contractions in isolated bovine mesenteric lymphatics. Am J Physiol 1993; 264:H1460-4. [PMID 8498560]
- Watanabe N, Kawai Y, Ohhashi T. Dual effects of histamine on spontaneous activity in isolated bovine mesenteric lymphatics. Microvasc Res 1988; 36:239- 49. [PMID 2906732]
- Hayashi A, Elias R, Nelson W, Hamilton SM, Johnston MG. Inhibition of intrinsic pumping activity in ovine mesenteric lymphatics during endotoxic shock. Curr Surg 1988; 45:131-4. [PMID 3365990]
- Elias RM, Johnston MG, Hayashi A, Nelson W. Decreased lymphatic pumping after intravenous endotoxin administration in sheep. Am J Physiol 1987; 253:H1349-57. [PMID 3425736]
- Elias RM, Johnston MG. Modulation of lymphatic pumping by lymph-borne factors after endotoxin administration in sheep. J Appl Physiol 1990; 68:199- 208. [PMID 2312460]
- Shirasawa Y, Ikomi F, Ohhashi T. Physiological roles of endogenous nitric oxide in lymphatic pump activity of rat mesentery in vivo. Am J Physiol Gastrointest Liver Physiol 2000; 278:G551-6. [PMID 10762608]
- von der Weid PY, Crowe MJ, Van Helden DF. Endothelium-dependent modulation of pacemaking in lymphatic vessels of the guinea-pig mesentery. J Physiol 1996; 493:563-75. [PMID 8782117]
- Sakai H, Ikomi F, Ohhashi T. Effects of endothelin on spontaneous contractions in lymph vessels. Am J Physiol 1999; 277:H459-66. [PMID 10444469]
- Ohhashi T, Olschowka JA, Jacobowitz DM. Vasoactive intestinal peptide inhibitory innervation in bovine mesenteric lymphatics. A histochemical and pharmacological study. Circ Res 1983; 53:535-8. [PMID 6138169]
- Zhao J, van Helden DF. ATP-induced endothelium-independent enhancement of lymphatic vasomotion in guinea-pig mesentery involves P2X and P2Y receptors. Br J Pharmacol 2002; 137:477-87. [PMID 12359629]
- Gao J, Zhao J, Rayner SE, Van Helden DF. Evidence that the ATP-induced increase in vasomotion of guinea-pig mesenteric lymphatics involves an endothelium-dependent release of thromboxane A2. Br J Pharmacol 1999; 127:1597-602. [PMID 10455315]
- Ohhashi T, Watanabe N, Kawai Y. Effects of atrial natriuretic peptide on isolated bovine mesenteric lymph vessels. Am J Physiol 1990; 259:H42-7. [PMID 2142859]
- Amerini S, Ziche M, Greiner ST, Zawieja DC. Effects of substance P on mesenteric lymphatic contractility in the rat. Lymphat Res Biol 2004; 2:2-10. [PMID 15609922]
- Rayner SE, Van Helden DF. Evidence that the substance P-induced enhancement of pacemaking in lymphatics of the guinea-pig mesentery occurs through endothelial release of thromboxane A2. Br J Pharmacol 1997; 121:1589-96. [PMID 9283691]
- Zawieja DC, Davis KL. Inhibition of the active lymph pump in rat mesenteric lymphatics by hydrogen peroxide. Lymphology 1993; 26:135-42. [PMID 8258987]
- Yokoyama S, Benoit JN. Effects of bradykinin on lymphatic pumping in rat mesentery. Am J Physiol 1996; 270:G752-6. [PMID 8967485]
- Takeshita T, Morio M, Kawahara M, Fujii K. Halothane-induced changes in contractions of mesenteric lymphatics of the rat. Lymphology 1998; 21:128-30. [PMID 3221719]
- McHale NG, Thornbury KD. The effect of anesthetics on lymphatic contractility. Microvasc Res 1989; 37:70-6. [PMID 2921950]
- Hattori J, Yamakage M, Seki S, Okazaki K, Namiki A. Inhibitory effects of the anesthetics propofol and sevoflurane on spontaneous lymphatic vessel activity in rats. Anesthesiology 2004; 101:687-94. [PMID 15329593]
- McHale N, Roddie I. The effect of transmural pressure on pumping activity in isolated bovine lymphatic vessels. J Physiol 1976; 261:255-69. [PMID 988184]
- Dreszer H, Slusarczyk K, Stoklosa E. Effect of vibration on the functioning of the lymphatic system in the small intestine in rat. Med Pr 1979; 30:331-6. [PMID 514069]
- McMahon AM, Carati CJ, Piller NB, Gannon BJ. The effects of radiation on the contractile activity of guinea pig mesenteric lymphatics. Lymphology 1994; 27:193-200. [PMID 7898134]
- Hayashi A, Johnston MG, Nelson W, Hamilton S, McHale NG. Increased intrinsic pumping of intestinal lymphatics following hemorrhage in anesthetized sheep. Circ Res 1987; 60:265-72. [PMID 3568295]
- Johnston MG, Elias RM, Hayashi, A, Nelson W. Role of the lymphatic circulatory system in shock. J Burn Care Rehabil 1987; 8:469-74. [PMID 3436971]
- Boulanger BR, Lloyd SJ, Walker M, Johnston MG. Intrinsic pumping of mesenteric lymphatics is increased after hemorrhage in awake sheep. Circ Shock 1994; 43:95-101. [PMID 7834825]
- Berdichevskii MS, Levin IuM, Miamlina GA, Blagoveshchenskaia RP. Lymphogenic detoxication in cardiogenic shock. Anesteziol Reanimatol 1980; 52-4. [PMID 6770725]
- Witte MH, Dumont AE, Clauss RH, Rader B, Levine N, Breed ES. Lymph circulation in congestive heart failure: effect of external thoracic duct drainage. Circulation 1969; 39:723-33. [PMID 5785287]
- Gushca AL, Iudin VA. External drainage of the thoracic duct in the complex treatment of acute circulatory disorders of the lower limbs. Khirurgiia (Mosk) 1983; 12:47-9. [PMID 6668829]
- Archvadze VG, Alekseev GI, Vasil'ev SA, Baranovich V, Domracheva EV. An intermittent method for drainage of the thoracic lymphatic duct in chronic lympholeukemia. Ter Arkh 1988; 60:89-92. [PMID 3175937]
- Logeais Y, Mathey J, Vanetti A, Binet JL, Bernard J. The drainage of the thoracic duct in the course of chronic lymphocytic leukemia. Nouv Rev Fr Hematol 1968; 8:565-70. [PMID 4237383]
- Chrobak L, Radochova D, Bartos V, Brzek V, Strnad L. The human thoracic duct lymph in malignant lymphomas. Sb Ved Pr Lek Fak Karlovy Univerzity Hradci Kralove 1976; 19:525-36. [PMID 1072536]
- Runovich AA, Alamov VT, Kulemin SP, Zuev AV, Sobotovich VF. Drainage of the thoracic duct in the treatment of severe forms of bronchial asthma. Klin Med (Mosk) 1983; 61:74-6. [PMID 6855162]
- Samsonov VP. Use of lymphosorption detoxication in the treatment of lung abscesses and their complications. Vestn Khir Im I I Grek 1988; 140:92-5. [PMID 3206780]
- Kochnev OS, Kim B. Drainage of the thoracic duct in peritonitis. Khirurgiia (Mosk) 1987; 3:44-8. [PMID 3586524]
- Toritsin AA. Thoracic duct drainage in the complex treatment of diffuse suppurative peritonitis. Khirurgiia (Mosk) 1981; 8:17-22. [PMID 7300174]
- Brzek V, Bartos V. The importance of the thoracic duct drainage for the diagnosis of pancreatic carcinoma. Sb Ved Pr Lek Fak Karlovy Univerzity Hradci Kralove 1972; 15:609-17. [PMID 4525479]
- Shurkalin BK, Krylov LB, Kriger AG, Shepilova ZhI. Lympho- and hemosorption in combined treatment of destructive pancreatitis. Klin Khir 1982; 11:42-3. [PMID 7154531]
- Brzek V, Bartos V. Temporary drainage of the thoracic duct in acute necrosis of the pancreas and chronic recurrent pancreatitis. Cas Lek Cesk 1968; 107:723. [PMID 5666291]
- Pashkevich VI, Stulov AP, Nekrasov VV, Overchenko AV. Thoracic duct drainage with lymphosorption in the combined treatment of serum hepatitis. Voen Med Zh 1981; 9:59-60. [PMID 7303538]
- Kovalev MM, Shevchenko VS, Gunchenko AN, Giatos DV. Thoracic duct drainage in the combined surgical treatment of obstructive jaundice patients. Klin Khir 1984; 9:9-12. [PMID 6492648]
- Shalimov SA, Zemskov VS, Kolesnikov EB. Drainage of the thoracic lymphatic duct and lymphosorption in the combined treatment of obstruction of the bile ducts and liver failure. Vestn Khir Im I I Grek 1982; 128:24-9. [PMID 7072053]
- Witte MH, Horowitz L, Dumont AE. Use of thoracic-duct cannulation in the diagnosis of tuberculous enteritis. N Engl J Med 1963; 268:1125-6. [PMID 14001395]
- Lytkin MI, Zubarev PN. External drainage of the thoracic lymphatic duct in emergency abdominal surgery. Voen Med Zh 1980; 1:30-4. [PMID 7376489]
- Kochnev OS, Davletkil'deev FA, Kim B. Characteristics of operations on the thoracic lymphatic duct in emergency surgery. Vestn Khir Im I I Grek 1979; 123:3-8. [PMID 505798]
- Kharaberiush VA, Kvasha VI, Siniachenko OV, Siniachenko VV. Drainage of the thoracic lymphatic duct as a method of pathogenic therapy in unspecific ulcerative colitis. Klin Khir 1979; 2:17-9. [PMID 430968]
- Briker VA, Glezer GA, Levin IuM. Thoracic lymphatic duct drainage in a female patient with exacerbated chronic glomerulonephritis. Sov Med 1980; 4:116-7. [PMID 7384871]
- Ono Y, Hirabayashi S, Yamada S, Ohshima S, Kinukawa T, Matsuura O, et al. Thoracic duct drainage pretreatment in living related kidney transplantation. Long-term results of low dose steroid and azathioprine immunosuppression. Nippon Hinyokika Gakkai Zasshi 1990; 81:221-4. [PMID 2325318]
- Ohshima S, Kinukawa T, Matsuura O, Takeuchi N, Hattori R, Hashimoto J, et al. Thoracic duct drainage pretreatment and low dose cyclosporine and low dose steroid immunosuppressive treatment in living related kidney transplantation. Nippon Hinyokika Gakkai Zasshi 1990; 81:225-9. [PMID 2325319]
- Takeuchi N, Ohshima S, Ono Y, Sahashi M, Matsuura O, Yamada S, et al. Five-year results of thoracic duct drainage in living related donor kidney transplantation. Transplant Proc 1992; 24:1421-3. [PMID 1496604]
- Siniachenko VV, Siniachenko OV, Kvasha VI, Diadyk AI, Kharaberiush VA. Drainage of thoracic lymph duct in the treatment of patients with rheumatoid arthritis. Ter Arkh 1982; 54:96-9. [PMID 7179164]
- Salavec M, Bartos V, Brzek V. Effect of prolonged external drainage of the thoracic duct in systemic connective tissue disorders (author's transl). Cas Lek Cesk 1975; 114:565-7. [PMID 1139601]
- Pekarskii DE, Maliasov GD. Drainage of the thoracic lymphatic duct in the treatment of acute toxemia in thermal burns. Klin Khir 1979; 3:7-10. [PMID 439664]
- McGregor DD, Gowans JL. Survival of homografts of skin in rats depleted of lymphocytes by chronic drainage from the thoracic duct. Lancet 1964; 15:629-32. [PMID 1410928]
- Atanasov D, Nenov K, Nenov D, Genova M. External drainage of the thoracic duct with and without lymphosorption in the endotoxic phase of phalloid mushroom poisoning. Khirurgiia (Sofiia) 1990; 43:105-10. [PMID 2102928]