Spontaneous, post-operative and traumatic chylothorax.

Study of the malformation of the chyliferous vessels, malformations of Pecquet's cistern or of the thoracic duct has brought out the nature of the physiopathology of spontaneous chylothorax: it is the result of a rupture of a lymphatic of the diaphragm, mediastinum, or lung. Post-operative chylothorax is due to a lesion of the thoracic duct or of one of its branches.

[Diagnosis of chyliferous blockage by the hyperlipidemia test (author's transl)]. / Diagnostic du blocage des chylifères par le test d'hyperlipidémie.

In our hyperlipidemia test, the total lipids curve, a plateau without a postprandial peak, allows an easy diagnosis of the chyliferous blockage. The malformation of chyliferous vessels produces the congenital forms: exsudative enteropathy, chyloperitoneum, spontaneous chylothorax, chylous cyst of the mediastinum, reflux of chyle in the pulmonary lymphatics, lymphoedema with chyle reflux in the lymphatics of the leg and chyluria. The acquired forms comprise the post-infectious sclerosis of the intestinal lymphatics and the neoplastic invasions of the mesenteric lymph nodes. The optical density curve brings some informations for a better understanding of lipid's absorption.

[Malformations of the lacteals]. / Les malformations des chylifères.

For the diagnosis of malformations of the lymphatics is made by the hyperlipidaemia test, which shows a flat total lipids curve without a post-prandial peak. Malformation of the lymphatics of the small intestine is responsible for exudative enteropathy, chyloperitoneum, chyluria, lymphoedema with reflux of lymph in the lymphatics of the legs and its complications (chylorrhagia, chylarthrosis), chylothorax, chylopericardium and reflux of lymph in the pulmonary lymphatics. This malformation can also be associated with other disorders : such as the syndrome of Klippel and Trenaunay, and simple lymphoedema of the limbs or genital organs. Lymphography of the intestinal lymphatics carried out during laparotomy after a fatty meal shows the state of the lymphatic vessels, a lack of injection of the cistern of Pecquet, and above all the presence of adventitious vessels allowing the lymph to reach the cervical region.

[The induced hyperlipemia test. 10 years of experience]. / Le test d'hyperlipidémie provoquée. Dix ans d'expérience.

The induced hyperlipemia test, which is easly to administer, yields very interesting information for the study of lipidic metabolism in arteriosclerosis patients. Its use, in both the pre- and post-operative phases, has brought out the valuable effect of ligature of the intestinal lymphatics in treating arteritis. It may also enable us to determine whether there is a hereditary factor or family predisposition to arteriosclerosis. Furthermore, the test makes it possible to confirm diagnosis of obstruction of the lymphatics of the gut in exsudative enteropathy and in various dysfunctious of the chyliferous vessels (sclerosis, rupture, tumoral invasion) without to resort to the use of radioactive substances.

[Chyloperitoneum causing intestinal obstruction]. / Chylopéritoine entraînant une occlusion intestinale

The two cases reported here show intestinal obstruction may occur by coagulation of lymph around the loops. They permit us to better understand the physiopathology of blockage of the lymph vessels whether congenital as in the first case or traumatic as in the second case. Traumatic rupture of the cisterns chyli is exceptional. The histological lesions observed on clamped biopsies show clearly the pathology of protein-losing enteropathy.

[Ligation of lymphatic ducts in treatment of arteriosclerosis. 550 operated cases reported over a period of 9 years]. / Ligature des chylifères dans le traitement de l'artériosclérose. 550 cas opérés en 9 ans

In all diseases where there is an important loss of lymph, e.g. chylothorax, chyloperitoneum, exsudative enteropathy chyloduodenal fistula, we observed not only a fall in the serum proteins and calcium, but also a fall in lipids and cholesterol. We first carried out ligature of the lymphatic ducts in numerous dogs. Since 1966, we have carried out this ligature in 550 arteriosclerotic patients, aged less than 52 years. The metabolic changes observed over a period of 9 years were very marked. Clinically, in 100 patients who underwent classical reconstructive arterial surgery, the association of ligature of the lymphatic ducts reduced by half, after a period of 6 years, the complications normally observed.

Hematuria and rectal bleeding in the child with Klippel and Trenaunay syndrome.

We have operated upon 588 patients with Klippel and Trenaunay syndrome. The underlying factor is a congenital malformation of the deep veins: agenesis, atresia or compression by fibrovascular bands of the popliteal, femoral or iliac veins. Of these 588 patients, 6 children between 15 months and 4 years of age had severe rectal bleeding and hematuria. One of these children died from massive bleeding of the rectum with septicemia. Another boy was saved by rectal resection and the last one by subtotal cystectomy. The important venogram shows an absence of the anterior venous pathway (superficial femoral vein) compensated by the abnormal development of 2 venous groups, the vein of the sciatic nerve and large veins along the external aspect of the inferior limb. These 2 venous groups penetrate into the pelvis by the sciatic and gluteal notches and terminate in the internal iliac vein which becomes enormous and has a very high flow. This overflow hinders drainage of the venous collateral from the rectum, the bladder and the vagina. The retro adductor vein, prolongated by the deep femoral vein, represents an anastomosis between the sciatic nerve vein and the common femoral vein. The surgeon must try to widen this pathway.

[Sclerosis of the intestinal lymphatic vessels]. / Sclérose des lymphatiques intestinaux

Fibrosis of the intestinal lymphatic vessels, produced in one case by tuberculosis and, in the other, by appendicitis and peritonitis, caused blockage of the main lymphatic vessels causing, clinically, a protein-losing enteropathy similar to that noted in congenital lymphatic diseases of childhood. In the laboratory, there was noted a fall in serum protein, lipid and cholesterol. A fat absorption test was very abnormal showing a flat curve. During laparotomy, there was discovered on the small intestine, the same layout of lymph vessels, resembling a lace network, as that observed in congenital malformations. Intestinal lymphography showed considerable stasis of the opaque substance and absence of injection of the lymph vessels in the mesentery.