淋巴介入：未来

Lymphatic Interventions-Future

将导管进入胸导管，这一前所未有的技术，除了带来有关淋巴管疾病的新认识和新疗法，也给人们一些想象的空间，淋巴介入也许可以走的更远，包括

胸导管外引流 Externalization of the Thoracic Duct

Gut-Lung syndrome
TD fluid sampling/harvesting
T-Cell depletion therapy

有人总结了20年来154篇文件，描述经由淋巴介入治疗的各类疾病，很多都不是我们先前栏目中介绍过得

Wang, H.-W., Escott, A. B. J., Phang, K. L., Petrov, M. S., Phillips, A. R. J., & Windsor, J. A. (2016). Indications, techniques, and clinical outcomes of thoracic duct interventions in patients: a forgotten literature? The Journal of Surgical Research, 204(1), 213–227.

这是1950-2014年（每5年一个时期）淋巴介入在器官移植、器官衰竭，自身免疫性疾病和包括胰腺炎、肿瘤、感染、结核和梗阻性黄疸的其它应用

从文献分布角度看，为什么我们当时几乎会把包括胸导管介入给忘了？

主要是对淋巴解剖缺乏理解Lack of understanding of the lymphatic anatomy
- 不是所有的淋巴液被引流 Not all of the lymphatic fluid is drained
外科技术复杂和困难 Complex and inconvenient surgical technique

外科手术外引流


Wang, H.-W., Escott, A. B. J., Phang, K. L., Petrov, M. S., Phillips, A. R. J., & Windsor, J. A. (2016). Indications, techniques, and clinical outcomes of thoracic duct interventions in patients: a forgotten literature? The Journal of Surgical Research, 204(1), 213–227

外科外引流手术

Variation of the Thoracic Duct

胸导管变异给传统的淋巴外引流带来更大的困难

而介入技术的发展，给淋巴介入带来技术上的便利

导丝圈套技术


圈套器经贵要静脉入路，进入锁骨下静脉的静脉角	圈套器抓住经胸导管出静脉角的0.018导丝，形成through-through通路


根据栓塞或覆膜支架释放需求不同，经导丝可以引入4-6Fr血管鞘	经血管鞘可以引入不同直径的导管进行胸导管栓塞，支架或外引流

胸导管外引流

先天性淋巴管发育不良胸导管外引流前后


引流前	引流后

下面是胸导管外引流治疗的另外一种病

肠-肺综合征 Gut-Lung syndrome

（包括百度、yahoo 和 google 未搜索到这个词，姑且暂用它吧）

Dugernier T, G, et al. Prospective evaluation of thoracic-duct drainage in the treatment of respiratory failure complicating severe acute pancreatitis. Intens Care Med. 1989

10 patients
TD lymph drainage led to a clinical improvement of abdominal pain, peritonitis, and shock
Larger volumes of TD lymph drained correlated with the greater clinical improvement

Brzek V, et al. Therapeutic effect of the prolonged thoracic duct lymph fistula in patients with acute pancreatitis. Digestion. 1969

12 patients
TD lymph drainage improved gas exchange in patients with respiratory impairment or acute respiratory distress syndrome (ARDS) secondary to acute pancreatitis
Arterial oxygenation began to improve as soon as TD lymph drainage was started

慢性心衰的胸导管外引流（淋巴减压）
Lymphatic Decompression in Congestive Heart Failure


WITTE, M. H., DUMONT, A. E., Clauss, R. H., RADER, B., LEVINE, N., & BREED, E. S. (1969). Lymph Circulation in Congestive Heart Failure, 39(6), 723–733. http://doi.org/10.1161/01.CIR.39.6.723

T细胞消耗（减少）治疗

T Cell Depletion Therapy

长期引流的TD淋巴结导致严重的细胞免疫抑制

Prolong drainage of the TD lymph results in profound cellular immunosuppression

应用于器官移植 Organ transplantation

- 显著改善急性器官排异反应 Significantly improved the or acute organ rejection

- 不影响长期生存 No effect on long term survival

显著临床改善下列患者 Marked clinical improvement in patients with:

- 严重顽固的风湿性关节炎 severe refractory rheumatoid arthritis

- 系统性红斑狼疮 systemic lupus erythematosus

- 硬皮病 scleroderma

下列患者临床某些改善 Some improvement in patients with:

- 血管球性肾炎 glomerulonephritis

- 多肌炎 polymyositis

- 假麻痹性重症肌无力 myasthenia gravis

- 多发硬化 multiple sclerosis

癌免疫治疗 CAR-T Cell Cancer Immune Therapy


Lim WA, June CH. The Principles of Engineering Immune Cells to Treat Cancer.Cell. 2017 Feb 9;168(4):724-740

未来

MRL and Lymphatic Embolization	慢性支气管炎 Chronic Bronchitis
	间质性肺疾病 Interstitial Lung Disease
	支气管肺发育异常 Bronchopulmonary Dysplasia
Liver Lymphatic Embolization	心源性腹水 Cardiac Ascities
Liver Lymphatic Embolization	肝硬化腹水 Liver Cirrhosis Ascities
Thoracic Duct Externalization	心衰 Heart Failure
	肠-肺综合征 Gut-Lung syndrome
	免疫治疗 (car T cell) Immunotherapy (car T cell)
	消耗T细胞治疗 T cell depletion therapy
Development of the new lymphatic imaging agents	Liver lymphatic Imaging
Development of the new lymphatic imaging agents	Intestinal Lymphatic Imaging

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淋巴介入的未来