Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach.     

Arterial blood supply to the pancreatic cauda and acute pancreatitis after splenectomy (author's transl)

Thirty cadaver dissections and injections of the pancreatic caudal arteries brought the authors to the conclusion that the ligature of a recurrent artery (going from the splenic hilum to the pancreatic cauda) is an exceptional cause of acute pancreatitis after splenectomy : this complication is more often due to direct trauma to the pancreas.     

Arterial supply to the hypogastric and presacral nerves

The hypogastric nerves take an arterial supply from the internal iliac artery either directly or from one of its main branches close to its origin from the parent trunk. Sometimes the supply is from the lower end of the common iliac artery. In half the cases examined the presacral nerve takes an arterial supply from the aorta at its bifurcation.     

Arterial blood gas determination in patients with anterior packing

Twenty-two healthy males ranging in age between 18 and 43 years were studied by arterial blood sample obtained before nasal surgery and again after complete bilateral nasal obstruction produced by nasal packing. Five of these patients had a third sample drawn after pack removal. The pO2 dropped from a preoperative mean of 85 mm Hg to 74 mm Hg. This difference is statistically significant; pCO2 did not change between the two measurements. This result is attributed to hypoxia caused by acute total nasal obstruction. It suggests that anterior packing alone may cause a clinically important hypoxia in patients with inadequate pulmonary reserve and that these patients merit close observation when bilateral anterior packing is placed. The early removal of anterior packing in patients where possible seems indicated. Supplemental O2 (40%) for patients over 40 years of age requiring nasal packing is practiced at this Center.     

Arterial blood supply to a left artrial myxoma diagnosed by coronary arteriography: report of a case

A patient with left atrial myxoma is described. Selective coronary arteriography visualized a cluster of abnormal vessels representing the vascularization of the tumoral mass localized in the left atrium.     

Intestinal anastomosis with the biofragmentable anastomosis ring

BACKGROUND: The fear of anastomotic complications prevents the spread of the use of the biofragmentable anastomosis ring (BAR) in intestinal surgery. PATIENTS AND METHODS: A total of 453 patients underwent intestinal resection and anastomosis with the BAR. RESULTS: In all, 514 anastomoses have been carried out, 424 (83%) in elective settings, and 90 (18%) in emergency. Fifty-one patients had multiple anastomoses. Reoperation was performed in 4 patients (1%) who had a complete anastomotic leakage. In 13 patients (3%), anastomotic leakage was partial, and only 1 patient required reoperation. No postoperative intestinal obstruction occurred. Four patients (1%) developed late anastomotic strictures, which have been treated by endoscopic dilation. CONCLUSIONS: The results of our experience and those of other large clinical series definitely confirm the effectiveness of the BAR method, which seems to be a standard, easy, rapid, and safe technique either in elective or emergency surgery.     

Arterial blood pressure measurement with oscillometric instruments in newborns and infants

Non-invasive blood pressure measurements by the auscultatory method do not provide reliable, reproducible blood pressure values in many neonates because the Korottkoff sounds are often very difficult to detect. This resulted in the development of many alternative indirect methods. Devices utilizing the Doppler ultrasound technique have not found wide acceptance. Since the introduction of automated oscillometric blood pressure monitors, arterial blood pressure has been increasingly brought into discussion as an indicator of the circulatory state. This is the first study to investigate the similarity and reproducibility of the data obtained with five oscillometric devices for measurement of blood pressure in neonates. MATERIALS AND METHODS. Since investigations on the technical performance are not practical in the clinical setting of a neonatal or pediatric ward, we used two simulators, the CuffLink (Dynatech, Nevada, USA) and a device developed by the PTB (Physikalisch-Technische Bundesanstalt). While the latter uses oscillations originally obtained from neonates, the CuffLink uses artificial and therefore ideal signals for the blood pressure monitors. The signals used for the PTB simulator were obtained from three neonates with an average age of 2 months and a weight of 3.5 kg, 4.4 kg, and 7.8 kg. The following blood pressure monitors were studied: Hoyer/Colin, BP-1001; Datex, Cardiocap II; SpaceLabs, model no. 90426; Hewlett-Packard, NBP M1008A; Critikon, Dinamap 1846. Before the measurements were started, the cuff pressure display of each monitor was checked according to a verification procedure. Although the 4 mmHg margin of error was not exceeded, the results were corrected. RESULTS. The results of the measurements show significant differences between the blood pressure monitors from the various manufacturers, with the differences for the ideal signals of the CuffLink-Simulator being less pronounced than those for the PTB simulator. Direct comparison of results is therefore often impossible. The standard deviation, taken from 20 measurements per monitor and simulation, is below 4 mmHg for both simulators. We can therefore conclude that the reproducibility of data is satisfactory and the emerging trend is reliable. DISCUSSION. The difference between the results of the PTB simulator and the CuffLink are probably due to the method of evaluation and the identification of artifacts of each blood pressure monitor. This is also confirmed by the studies of Mieke et al. The manufacturers should provide devices that display comparative results and improve the algorithms for detection of artefacts, increasing the accuracy of their blood pressure monitors. This could be done with the help of simulators. Considering the pathophysiological characteristics of neonates and infants, the systematic differences between the five monitors have to be regarded as serious.     

Arterial blood gases in acute pulmonary edema

Arterial blood gas and pH measurements in 82 patients with acute pulmonary edema of cardiogenic origin entering the emergency department varied widely and were unpredictable using clinical examination. The mean arterial oxygen tension (PaO2) measured in 71 patients breathing room air was 59 mm Hg. Fourteen of the 82 patients were acidemic; 35, alkalemic and 33 had a pH in the normal range. The acidemic group had markedly lower PaO2, all under 60 mm Hg. Oxygen and furosemide were used in all cases and effectively corrected the hypoxia and reduced pulmonary congestion. Other drugs used included aminophylline (14 patients), morphine sulfate (9 patients) and digoxin (3 patients). Five of the nine patients who received morphine were hypercarbic initially but the CO2 retention did not worsen. No patient died during the initial 48 hours. This study reiterates the importance of directing therapy at ventilatory and cardiac abnormalities and points out the value of arterial blood gas monitoring to assess the initial status, monitor the patient's course, and to select drug therapy.     

Anomalous double blood supply to the lung

We report an unusual case in which an apparently normal upper lobe of the right lung was supplied by major systemic arterial and pulmonary arterial vessels. The anomalous artery arose from the descending aorta. Following interruption of this vessel, the machinery-like murmur previously present disappeared.     

Tissue and blood CEA levels in stomach cancer

The assays of serum CEA is a useful prognostic marker in patients with stomach cancer. In this study pre-operative serum CEA and tissue CEA in tumour or biopsy were assayed in a group of patients with gastric carcinoma in order to assess their prognostic roles. Based on an analysis of the results the authors affirm that high serum CEA levels in patients with advanced stages of stomach cancer indicate a fatal prognosis, and likewise the finding of tissue CEA in loco-regional lymph nodes at the same concentration as that in the primary tumour is also the sign of a severe prognosis.     

Arterial blood pressure responses to cell-free hemoglobin solutions and the reaction with nitric oxide

Changes in mean arterial pressure were monitored in rats following 50% isovolemic exchange transfusion with solutions of chemically modified hemoglobins. Blood pressure responses fall into three categories: 1) an immediate and sustained increase, 2) an immediate yet transient increase, or 3) no significant change either during or subsequent to exchange transfusion. The reactivities of these hemoglobins with nitric monoxide (.NO) were measured to test the hypothesis that different blood pressure responses to these solutions result from differences in .NO scavenging reactions. All hemoglobins studied exhibited a value of 30 microM-1 s-1 for both .NO bimolecular association rate constants and the rate constants for .NO-induced oxidation in vitro. Only the .NO dissociation rate constants and, thus, the equilibrium dissociation constants varied. Values of equilibrium dissociation constants ranged from 2 to 14 pM and varied inversely with vasopressor response. Hemoglobin solutions that exhibited either transient or no significant increase in blood pressure showed tighter .NO binding affinities than hemoglobin solutions that exhibited sustained increases. These results suggest that blood pressure increases observed upon exchange transfusion with cell-free hemoglobin solutions can not be the result of .NO scavenging reactions at the heme, but rather must be due to alternative physiologic mechanisms.     

Microangioarchitectonics and microtopography of the blood vessels of the human stomach

The data of previous investigations on general principles of microarchitectonics of the human intraorganic gastric vessels have been checked. Peculiarities of branching and course of the stomach intraorganic vessels, arterio-venous anastomoses, twisted arterioles, sinusoid venules and veins confirm activity and variability of the organ's circulation at microcirculatory level. Certain slight differences in diameters and number of microvessels have been revealed in some anatomical parts of the serous membrane and submucous layer of the stomach. Maximal differences in vessel diameters of the microcirculatory bed and in number of capillaries per 1 mm2 have been revealed in the most active layers of the gastric wall--in muscular and mucous membranes. In the muscular membrane, large vessels and greater number of capillaries have been revealed in the area of the greater curvature and the pylorus. In the serous membrane in the pyloric area and in the area of the smaller curvature, microvessels have smaller diameters and the number of capillaries per square unit is less.