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Endoscopic transgastric lymphangiography in the canine stomach
Endoscopic transgastric lymphangiography in the canine stomach A preliminary report of a new technique
Jeffrey L. Ponsky, MD Helmut Schreiber, MD Errol Bellon, MD
Indirect lymphangiography by endoscopically guided injection of contrast material into the upper gastrointestinal walls of dogs was undertaken to demonstrate the feasibility of opacifying visceral lymph nodes. Further investigation may lead to the application of this potentially valuable technique in patients. Direct lymphangiography involving injection of pedal lymphatics is a useful technique in the demonstration of inguinal, iliac, and para-aortic lymph nodes. This method does not provide visualization of abdominal visceral lymphatics and is of little value in assessing the presence of abdominal malignancies.' Indirect lymphangiography is a technique in which contrast material is injected into body tissues with subsequent uptake by regional lymphatics and radiographic opacification of local lymph glands. Introduction of contrast material into the peritoneal cavity of animals has produced excellent visualization of mediastinal lymph nodes by this method, but again no abdominal visceral nodes were opacified. 2 We have utilized the principles of indirect lymphangiography in combination with endoscopic injection in an attempt to provide radiographic demonstration of the perigastric lymph nodes. Reports of indirect lymphography of the stomach in animals' and humanss have appeared sporadically in the foreign literature. We feel that the details and consequences of this technique must be established in animals prior to its application in human subjects.
Figure 1. Endoscopic view of mucosal bleb at injection site. METHOD Six adult mongrel dogs were maintained without oral intake for 24 hours. Each dog was anesthetized, and esophagogastroscopy was performed. Submucosal injections were performed using the Olympus NM-l K endoscopic injection catheter. The contrast material used was Ethiodol, which is an ethiodized oil containing 37% iodine in organic combination with the ethyl esters of the fatty acids of poppy seed oi I. Each injection was performed using 1 ml of contrast material in a tuberculin syringe. This minimizes the force required to inject the high viscosity fluid through the long, small bore catheter. The needle tip of the catheter was introduced through the gastric mucosa at an oblique angle to avoid perforation of the gastric wall. A small mucosal bleb was formed at the injection site (Figure 1). Injections were made at different sites in each animal. These
Cleveland, Ohio
included the anterior and posterior walls of the gastric body and antrum, the greater and lesser curvatures of the gastric body and antrum, a combination of these 8 sites, the gastric angle alone, the esophagus, and the duodenum (Figure 2). Roentgenograms were obtained immediately, at 72 hours, at 2 weeks, and at 1 month following injection. Several of the animals were sacrificed at 1 month following injection for radiographic and histologic examination. RESULTS In the first animal studied, radiographs were taken at frequent intervals following injection. No lymph node visualization was evident until 72 hours. Therefore, in the remaining animals no films were taken between the initial and the 72 hour films. In all animals which ultimately demonstrated opacification of lymph nodes, some nodes were apparent in the 72 hour film. There wasan increase inthe numberof nodes opacified between the 72 hour and the 2 week films. No significant increase in the number of nodes seen occurred after the initial2 week period. The best demonstration of perigastric lymph nodes was obtained with injection of the anterior and posterior walls of the gastric body and antrum (Figure 3). Opacification obtained after injection of the greater and lesser curvatures of the antrum and body of the stomach was of poor quality. When these 8 sites were all injected in 1 animal, there was excellent nodal opacification, but this was somewhat obscured by the large amount of contrast material retained in the gastric wall. A single injection at the gastric angle produced nodal opacification but significantly less than that obtained with 4 in·ections. DOG- 1
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Figure 2. Sites of endoscopic injections.
From the departments of Surgery and Radiology of the Casse Western Reserve University School of Medicine and University Hospitals of Cleveland. Reprint requests: Jeffrey l. Ponsky, MD, Department of Surgery, University Hospitals of Cleveland, 2065 Adelbert Road, Cleveland, Ohio 44106. VOLUME 23, NO.1, 1976
25
Figure 3. A, Radiograph taken immediately after injection of the anterior and posterior walls of the gastric body and antrum. B, Radiograph taken 2 weeks after injection of these sites; lymph nodes are clearly seen.
Esophageal injection produced no nodal opacification. Rather, the contrast material continued to diffuse throughout the esophageal wall. Duodenal injection revealed no nodes; however, this may have resulted from faulty injection. No contrast material remained in the duodenal wall at 72 hours following injection.
Figure 4. Radiograph of an extirpated canine stomach with surrounding mesenteries 1 month after injection.
When the animals were sacrificed, the stomach, omentum, duodenum, and the surrounding mesenteries were resected en bloc. Radiographic examination of these specimens confirmed the presence of opacified lymph nodes in the perigastric tissue, including nodes in the greater and lesser omentum and the periduodenal area (Figure 4). Histologic examination of the gastric injection sites revealed the submucosa to be filled with the lipid contrast material (Figure SA). A
granulomatous inflammatory response as previously described' with the use of Ethiodol was evident both at the injection sites and in the opacified lymphoid tissue. The lipid material forms the center of the granu lomatous response and is surrounded by a collar of epithelioid cells (Figure 58). No evidence of tissue necrosis was present. DISCUSSION Conventional direct lymphangiography does not demonstrate abdominal visceral lymph nodes and is of limited value in the assessment of abdominal malignancies. In the present study we have been able to produce opacification of the peri gastric lymph nodes in the canine stomach by combining the principles of indirect lymphangiography and endoscopic injection. Best results were obtained with submucosal injections in the anterior and posterior walls of the gastric body and antrum. More work is required to accurately define the sites of injection and the volume of contrast agent which will produce optimal nodal visualization. Additional study of duodenal injection may also provide opacification of the peri pancreatic lymph nodes. Demonstration of the peri gastric lymphatics may have important implications in the diagnosis, management, and treatment of abdominal visceral malignancies. Further study is in progress to evaluate this method and its application to human subjects.
REFERENCES 1. KOEHLER PR: Current status of lymphography in patients with cancer. Cancer (Conference Supplement) 37:503-516, 1976 2. BENNEIT HS, SHIVAS AA: The visualization of lymph nodes and vessels by ethyl iodostearate (Angiopac) and its effect on lymphoid tissue. J Fac Radiol 5:261, 1954 3. PETERS HI, BROWN M, PARRISH RA: Evolution of contrast medium granuloma in lymph nodes following lymphangiography. Am J Path 48:7a, 1966
Figure 5. A, Lipid (elliptical spaces) forms centers of granulomatous response surrounded by collar of epithelioid cells (H & Ex 124). S, Lipid in submucosa of gastric injection site (H & E x 23). 26
GASTROINTESTINAL ENDOSCOPY
Jeffrey L. Ponsky, MD Helmut Schreiber, MD Errol Bellon, MD
Indirect lymphangiography by endoscopically guided injection of contrast material into the upper gastrointestinal walls of dogs was undertaken to demonstrate the feasibility of opacifying visceral lymph nodes. Further investigation may lead to the application of this potentially valuable technique in patients. Direct lymphangiography involving injection of pedal lymphatics is a useful technique in the demonstration of inguinal, iliac, and para-aortic lymph nodes. This method does not provide visualization of abdominal visceral lymphatics and is of little value in assessing the presence of abdominal malignancies.' Indirect lymphangiography is a technique in which contrast material is injected into body tissues with subsequent uptake by regional lymphatics and radiographic opacification of local lymph glands. Introduction of contrast material into the peritoneal cavity of animals has produced excellent visualization of mediastinal lymph nodes by this method, but again no abdominal visceral nodes were opacified. 2 We have utilized the principles of indirect lymphangiography in combination with endoscopic injection in an attempt to provide radiographic demonstration of the perigastric lymph nodes. Reports of indirect lymphography of the stomach in animals' and humanss have appeared sporadically in the foreign literature. We feel that the details and consequences of this technique must be established in animals prior to its application in human subjects.
Figure 1. Endoscopic view of mucosal bleb at injection site. METHOD Six adult mongrel dogs were maintained without oral intake for 24 hours. Each dog was anesthetized, and esophagogastroscopy was performed. Submucosal injections were performed using the Olympus NM-l K endoscopic injection catheter. The contrast material used was Ethiodol, which is an ethiodized oil containing 37% iodine in organic combination with the ethyl esters of the fatty acids of poppy seed oi I. Each injection was performed using 1 ml of contrast material in a tuberculin syringe. This minimizes the force required to inject the high viscosity fluid through the long, small bore catheter. The needle tip of the catheter was introduced through the gastric mucosa at an oblique angle to avoid perforation of the gastric wall. A small mucosal bleb was formed at the injection site (Figure 1). Injections were made at different sites in each animal. These
Cleveland, Ohio
included the anterior and posterior walls of the gastric body and antrum, the greater and lesser curvatures of the gastric body and antrum, a combination of these 8 sites, the gastric angle alone, the esophagus, and the duodenum (Figure 2). Roentgenograms were obtained immediately, at 72 hours, at 2 weeks, and at 1 month following injection. Several of the animals were sacrificed at 1 month following injection for radiographic and histologic examination. RESULTS In the first animal studied, radiographs were taken at frequent intervals following injection. No lymph node visualization was evident until 72 hours. Therefore, in the remaining animals no films were taken between the initial and the 72 hour films. In all animals which ultimately demonstrated opacification of lymph nodes, some nodes were apparent in the 72 hour film. There wasan increase inthe numberof nodes opacified between the 72 hour and the 2 week films. No significant increase in the number of nodes seen occurred after the initial2 week period. The best demonstration of perigastric lymph nodes was obtained with injection of the anterior and posterior walls of the gastric body and antrum (Figure 3). Opacification obtained after injection of the greater and lesser curvatures of the antrum and body of the stomach was of poor quality. When these 8 sites were all injected in 1 animal, there was excellent nodal opacification, but this was somewhat obscured by the large amount of contrast material retained in the gastric wall. A single injection at the gastric angle produced nodal opacification but significantly less than that obtained with 4 in·ections. DOG- 1
lJ.
DOG ;>.
o
OOG
t>. ANOO
:5
DOG' 't [)Ofr
5
DOlT <;
o
•
•
.:: .~.~.~:.::..
Figure 2. Sites of endoscopic injections.
From the departments of Surgery and Radiology of the Casse Western Reserve University School of Medicine and University Hospitals of Cleveland. Reprint requests: Jeffrey l. Ponsky, MD, Department of Surgery, University Hospitals of Cleveland, 2065 Adelbert Road, Cleveland, Ohio 44106. VOLUME 23, NO.1, 1976
25
Figure 3. A, Radiograph taken immediately after injection of the anterior and posterior walls of the gastric body and antrum. B, Radiograph taken 2 weeks after injection of these sites; lymph nodes are clearly seen.
Esophageal injection produced no nodal opacification. Rather, the contrast material continued to diffuse throughout the esophageal wall. Duodenal injection revealed no nodes; however, this may have resulted from faulty injection. No contrast material remained in the duodenal wall at 72 hours following injection.
Figure 4. Radiograph of an extirpated canine stomach with surrounding mesenteries 1 month after injection.
When the animals were sacrificed, the stomach, omentum, duodenum, and the surrounding mesenteries were resected en bloc. Radiographic examination of these specimens confirmed the presence of opacified lymph nodes in the perigastric tissue, including nodes in the greater and lesser omentum and the periduodenal area (Figure 4). Histologic examination of the gastric injection sites revealed the submucosa to be filled with the lipid contrast material (Figure SA). A
granulomatous inflammatory response as previously described' with the use of Ethiodol was evident both at the injection sites and in the opacified lymphoid tissue. The lipid material forms the center of the granu lomatous response and is surrounded by a collar of epithelioid cells (Figure 58). No evidence of tissue necrosis was present. DISCUSSION Conventional direct lymphangiography does not demonstrate abdominal visceral lymph nodes and is of limited value in the assessment of abdominal malignancies. In the present study we have been able to produce opacification of the peri gastric lymph nodes in the canine stomach by combining the principles of indirect lymphangiography and endoscopic injection. Best results were obtained with submucosal injections in the anterior and posterior walls of the gastric body and antrum. More work is required to accurately define the sites of injection and the volume of contrast agent which will produce optimal nodal visualization. Additional study of duodenal injection may also provide opacification of the peri pancreatic lymph nodes. Demonstration of the peri gastric lymphatics may have important implications in the diagnosis, management, and treatment of abdominal visceral malignancies. Further study is in progress to evaluate this method and its application to human subjects.
REFERENCES 1. KOEHLER PR: Current status of lymphography in patients with cancer. Cancer (Conference Supplement) 37:503-516, 1976 2. BENNEIT HS, SHIVAS AA: The visualization of lymph nodes and vessels by ethyl iodostearate (Angiopac) and its effect on lymphoid tissue. J Fac Radiol 5:261, 1954 3. PETERS HI, BROWN M, PARRISH RA: Evolution of contrast medium granuloma in lymph nodes following lymphangiography. Am J Path 48:7a, 1966
Figure 5. A, Lipid (elliptical spaces) forms centers of granulomatous response surrounded by collar of epithelioid cells (H & Ex 124). S, Lipid in submucosa of gastric injection site (H & E x 23). 26
GASTROINTESTINAL ENDOSCOPY