Abstracts
1998 Digestive Disease Week

#1056

THE THORACIC DUCT IS NOT A MAJOR ROUTE OF BACTERIAL TRANSLOCATION IN PATIENTS WITH MULTIPLE ORGAN FAILURE. L.C.J.M. Lemaire,1,2 J.J.B. van Lanschot,1 C.P Stoutenbeek,3 S.J.H. van Deventer,2 J. Dankert,4 D.J. Gouma1. Depts. of Surgery,1 Intensive Care Medicine,3 and Microbiology4 and the Laboratory for Experimental Internal Medicine2, Academic Medical Centre, Amsterdam, The Netherlands.

Bacterial translocation has been nominated as a causative factor for the development of multiple organ failure (MOF) in patients without an infectious focus. Most studies have investigated the hematogenic route, but it has frequently been hypothesized that lymphatic translocation via the thoracic duct might be the major route of bacterial translocation. However, translocation beyond the mesenteric lymph nodes (at the level of the thoracic duct) has rarely been studied. The aim of this study was to determine whether bacterial translocation into the thoracic duct occurs in patients with MOF. Patients who had developed organ failure of two organ(s)(systems), caused either by generalized fecal peritonitis (n=4), or by a process without evidence of infection (n=4) were included in the study group. Patients without MOF (n=19), undergoing a transthoracic esophageal resection, including the thoracic duct, served as controls. The thoracic duct was drained for five days in the study group, and once peroperatively in the controls. In lymph and blood, bacterial cultures were performed, and concentrations of endotoxin and cytokines were simultaneously measured, once in the control group and at t=0, 3, 6, 12, 24, 48, 72, 96, and 120 hours in the study group. In five MOF-patients, all lymph (n=40) and blood cultures (n=40) were negative. Two patients had a positive lymph culture once (2/18), and one patient had a positive blood culture once (1/9), all yielding enteric bacteria. The median lymph and blood endotoxin concentrations, ranging from 39 to 63 Endotoxin Units (EU)/L, were low in MOF-patients. There were no significant differences between endotoxin concentrations in lymph and blood of MOF-patients; nor between blood of patients with and without MOF, or lymph of patients with and without MOF. In lymph and blood of MOF-patients, concentrations of TNF-_, IL-1_, IFN-_ and IL-12 were low, and comparable to concentrations in patients without MOF. The concentrations of endogenous inhibitors (soluble TNF-receptors, IL-1RA), were thousand-fold higher than their corresponding cytokine, both in lymph and blood of MOF-patients, and were significantly higher in lymph and blood of patients with MOF, as compared to lymph and blood of patients without MOF (p<0.01). In patients with MOF, IL-6, IL-10 and soluble-TNF-receptor p55 concentrations were significantly higher in lymph than in blood (p<0.03), suggesting transport of locally produced cytokines. Conclusion: Translocation of enteric bacteria and endotoxin occurs into the thoracic duct, but there was no difference in the extent of translocation between patients with and without MOF. In lymph and blood of MOF-patients, pro-inflammatory cytokine concentrations were low, and anti-inflammatory cytokine concentrations were high as compared patients without MOF. Whether this reflects a different effect of bacterial translocation in patients with MOF, compared to patients without MOF, due to a changed immune status, remains to be determined.

Copyright 1996 - 1998, SSAT, Inc. Revised 29 June 1998.