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Three patients developed chylous leakage after major blunt trauma. In one patient with non-remitting right-sided chylothorax, lymphangioscintigraphy as well as conventional oil contrast lymphography demonstrated disruption of the thoracic duct at the aortic hiatus which eventually required transpleural mediastinal ductal ligation proximal to the fistula. The other two patients had chylous retroperitoneum and/or chylous peritoneum which was self-limited although one patient (a three-year-old boy) died of multiorgan failure from associated pulmonary contusions and cervical spine injuries. Chylous leak after non-penetrating trauma is usually attributed to hyperflexion-extension of the vertebral column with shearing of tethered lymphatics. Alternatively, sudden compression of lipemic and engorged mesenteric lymphatics, adjacent nodes and the lower thoracic duct aggravated by deformations associated with stretching and tearing motions may also directly disrupt chyle-containing lymphatics.

Whereas clinical descriptions of grotesque lymphedema and standard light microscopy in human filariasis have elucidated the natural progression of this disease, the link between the nematode and vascular abnormalities including elephantiasis remains poorly understood. Accordingly, we examined the nature and distribution of lymphatic and blood vascular derangements in a variety of tissues and organs from 37 ferrets acutely and chronically infected with Brugia malayi and in 15 patients with Wuchereria bancrofti or Brugia malayi infestation (resected skin, subcutaneous tissue, and lymph nodes) using light and transmission electron microscopy, immunohistochemistry, and in vivo microscopy. In ferrets, eosinophilic abscesses and epithelioid and giant cell granulomas with fragmented worms in various stages of disintegration were found in multiple organs. Blood microvasculopathy consisted of endothelial hyperplasia, focal thickening and stenosis, vessel obliteration with marked perivascular infiltration of lymphocytes, plasma cells, eosinophils, and numerous large macrophages laden with a coarse golden-brown pigment. Endothelial ballooning and swelling, pavementing, denuding, scarring, and sludge formation were seen along with high endothelium in atypical locations. Dilated lymphatics were most prominent near adult worms and showed plump endothelium, thickened walls and valves, thrombus formation, and often perilymphangitis and adjacent tissue fibrosis. In vivo microscopy showed wriggling live adult worms in dilated incompetent sludge-filled groin lymphatics even when microfilaremia and peripheral edema were absent. In human tissues, in addition to "pachyderm" skin changes (keratosis, papillomatosis, acanthosis and collagen deposition), there was blood vessel and lymphatic vasculopathy similar to ferrets (angiocentric inflammation, congestion, vasculitis, thrombosis, thickened vessel walls, dilated lymphatics, lymphangitis, reactive lymph nodal hyperplasia and nodal fibrosis). These changes reflect generalized endothelial damage due to worm products, physical injury to valves and vessel walls from lymphatic-dwelling live worms, and host immune reactivity. Whereas adult worms target the lymphatic apparatus, their offspring and the host immune response primarily affects the blood microvasculature.

The role of antireflux operations in the elderly is ill-defined. Often, these patients are managed medically despite refractory symptoms for fear of surgical morbidity and mortality by referring physicians. This investigation was done to review the referral patterns and results of antireflux operations for patients more than 60 years old. The charts of all patients undergoing operation for reflux were reviewed during an eight year period from 1981 to 1989. One hundred and three patients underwent Nissen fundoplication. All patients had been treated with H2 blockers or antacids, or both, prior to referral for operation. Group 1 (N = 43) consisted of all patients who were 60 years of age and group 2 (N = 60), all patients less than 60 years of age. The mean age of those in group 1 was 70.6 years versus 43.7 years for those in group 2. The mean duration of symptoms was far greater in the elderly group versus the younger group (14.4 versus 4.1 years) (p less than 0.001). Twenty-eight patients in group 1 were referred for surgical treatment because of complications of reflux versus only four in group 2 (p less than 0.01) in whom intractability was the main indication for surgical treatment. The specific complications of gastroesophageal reflux disease that led to the referral of elderly patients for operation were stricture, bleeding, aspiration and Barrett's esophagus. There was one death and this occurred in a 46 year old woman who had a massive pulmonary embolism postoperatively. The mean duration of follow-up study was 5.1 years. Improvement in symptoms was noted by 37 patients in group 1 versus 56 in group 2. We conclude that elderly patients are most often referred for antireflux operations for complications of reflux versus younger patients in whom intractability is the most common indication. Earlier referral is warranted if reflux symptoms persist despite adequate medical therapy. Despite advanced esophageal disease, the results of antireflux operations are good, and surgical morbidity and mortality rates are low enough to warrant intervention in this group of patients, provided no medical contraindications exist.

Whole body lymphangioscintigraphy was performed after intradermal injection of 99mtechnetium human serum albumin or antimony colloid in the distal hindlimbs and forelimbs of ferrets chronically infected with Brugia malayi. The findings were compared with control ferrets and those with surgical interruption of the iliac lymphatics. While only one infected ferret manifested chronic hindlimb lymphedema, all exhibited delayed transport of radioisotope from the hindpaw with obstruction in the groin, poor or absent visualization of central lymphatic channels and regional lymph nodes, a picture similar to that following surgically induced lymphatic obstruction. In control ferrets, there was prompt visualization of peripheral lymphatic channels and regional lymph nodes with sharper and more extensive channel visualization after radiolabeled albumin and more intense sustained nodal visualization after radiolabeled antimony colloid. This noninvasive technique provides a readily repeatable investigative tool adaptable to small animals to study the evolution of lymphatic filariasis and other conditions associated with lymphatic obstruction.