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Current management of benign and malignant esophageal lesions has changed little in the past 25 years. Treatment of unresectable lesions has consisted primarily of exclusion and bypass procedures as well as prosthetic intubations for relief of dysphagia. A case of a Celestin tube fragmentation in a patient with unresectable esophageal carcinoma causing small bowel obstruction is presented. Diagnosis, management, and review of the literature are discussed. Recommendations for use of the Celestin tube in patients with good long-term prognoses include keeping a high index of suspicion for possible complications, close and regular radiographic and endoscopic follow-up, and early surgical intervention upon tube fragmentation.

A simple heparinless venoarterial bypass (HL-VAB) system without oxygenation has been developed for the support of the failing heart. Experiments in animals with cardiogenic shock showed that the aortic root pressure (coronary flow) was elevated immediately by HL-VAB. Within 90 minutes of HL-VAB, left ventricular dyskinesia disappeared and the bypass was successfully removed from all animals. Normal blood levels could easily be maintained by ventilatory support with 40% oxygen, if the bypass flow was not more than one third of the cardiac output. This technique was employed to mechanically support the circulation before and after surgery in five critically ill patients who underwent open-heart surgery. Four of the five patients survived. This technique of mechanical circulatory assistance appears to be simpler and more effective than other techniques employed clinically.

• We performed a prospective study in 207 patients with unstable angina pectoris (UA) to identify factors associated with operative mortality (OM) and perioperative myocardial infarction (Ml) from myocardial revascularization. The OM was 3.9% (8/207) and the incidence of Ml was 11% (23/207). Clinical variables (age, prior Ml, electrocardiographic evidence, symptoms, left ventricular function) and operative variables (incomplete revascularization, cardiopulmonary bypass time, cross-clamp time) did not correlate with OM or Ml. Operative mortality was associated with critical triple-vessel disease, but not left main coronary artery disease, and accounted for seven of the eight deaths (P<.01). Myocardial infarction was associated with elective surgery (22/167) as opposed to urgent surgery (1/40) (P<.01). Therefore, patients with critical triple-vessel disease are the highest risk group for OM, and urgent operation seems to reduce the incidence of Ml in patients with UA.(Arch Surg 1985;120:279-282)

ABSTRACT: In the elderly, a transient ischemic attack (TIA) and a hypersensitive carotid sinus reflex (HCSR) often co‐exist and can pose a diagnostic challenge. Seven cases are presented. HCSR is a relative condition; besides increased irritability of the receptor or target organs, susceptibility of the nerve center to ischemia probably is induced by a slow heart rate or low blood pressure in any patient with pre‐existing occlusive cerebrovascular disease. Dizziness and syncope of this type represent hemodynamic TIA in contrast to thromboembolic TIA. The carotid sinus massage test is recommended for differentiating the two types of TIA; the treatments differ. At present there is no uniform management that can be applied to either TIA or HCSR routinely. Therefore, treatment should be approached on an individual basis, keeping in mind the different pathophysiologic factors operating in the specific patient.

Five groups of seven dogs were studied. Each animal had 250 ml of blood withdrawn and tagged with Cr31. Group I (control) samples were combined with 500 ml of lactated Ringer’s solution and reinfused into the respective animals after 3 hours of incubation at 37° C. Group II samples were pumped in a closed-circuit bubble oxygenator with 500 ml of lactated Ringer’s prime for 2 hours before reinfusion into the animals. Group III samples were pumped in a bubble oxygenator for 3 hours before reinfusion. Group IV samples were pumped in a closed-circuit membrane oxygenator for 2 hours, and Group V samples were pumped in a membrane circuit for 3 hours. All extracorporeal pump runs were performed at 37° C. Blood samples were drawn from the dogs at regular intervals after bypass for 30 days. Erythrocyte survival was determined by Cr31activity recorded by a gamma counter. The red cell half-life was determined for each dog. The control half-life was 24.1 ± 2.03 days; Group II, 19.88 ± 1.69 (p < 0.05); Group III, 9.63 ± 1.4 (p < 0.001); Group IV, 19.4 ± 1.65 (p < 0.05); and Group V, 9.13 ± 1.45 (p < 0.001). These data indicate that serious red cell injury does occur with extracorporeal circulation but that the injury is a function of pump time, rather than of the type of oxygenator.

• We used multivariate analysis to determine whether survival following perforations of the gastrointestinal tract could be accurately predicted from preoperative data. Of 12 variables tested, four were found to have predictive value. These were age, pulmonary disease, preoperative shock, and the attending surgeon. When these four variables were employed in a logistic regression equation on 42 patients, it correctly predicted which 21 patients died before leaving the hospital. To produce an equation useful for other hospitals, we recalculated it without the attending surgeon variable. Again, the equation was used to predict survival. The correlation of predicted vs observed outcome remained high, and, using a 2×2 χ2 test, the correlation was significant. We then cross validated the three-variable model on data from a second hospital. The model accurately predicted the new data equally well. We believe that predictive models can identify risk factors in a variety of patient populations and can determine who is likely to benefit from specific treatment modalities.(Arch Surg 1988;123:354-357)

SUMMARY

Although the general term "postgastrectomy syndrome" is sometimes used to describe the numerous anatomical and physiological disturbances that may appear following operations upon the stomach, it is well recognized that the postgastrectomy syndrome is, in fact, a group of more or less distinct entities often occurring together in varying degrees of severity. Loss of the gastric reservoir function, incomplete obstruction of the gastric outlet, stagnation-obstruction of an afferent loop, anemia, multiple nutritional disturbances, and the dumping syndrome constitute the major categories within the postgastrectomy syndrome. Successful management of patients suffering from one or more of these conditions depends upon the clinician's ability to establish the nature of the pathology present in a particular patient. Our experiences with the identification and surgical treatment of the dumping syndrome are the subject of this report.One of the difficulties confronting those attempting to study and treat the dumping syndrome is the wide discrepancy

DURING the past 25 years, the safety and efficacy of vagotomy combined with a drainage procedure have led to widespread acceptance of this procedure in the treatment of duodenal ulcer. On the basis of this experience, it is not surprising that vagotomy and pyloroplasty have been advocated for the treatment of benign gastric ulceration as well.Although there is good experimental evidence that vagotomy decreases the humoral stimulus to the secretion of acid, other experimental evidence has shown that antral stasis will cause continued release of gastrin and stimulation of gastric secretions.1-4 Should vagotomy accentuate gastric stasis when the antrum is present, it could prove deleterious to the healing of a gastric ulcer. Clinical studies both support and reject the effectiveness of vagotomy and pyloroplasty for gastric ulcer in the absence of hypersecretion. Farris and Kraft have reported excellent results with this procedure while Woodward and Herrington have found

INTRODUCTION From 1941 to 1959 at the University of Chicago Clinics there have been 33 patients diagnosed as having a congenitally short esophagus. Eight of these had an associated adenocarcinoma at the esophagogastric junction. The significance of this 24% incidence seemed to merit further investigation. HISTORICAL The first reference to esophageal hiatus hernia was made by Ambrose Paré in 1610. The presence of a thoracic stomach with a congenitally short esophagus was described by Richard Bright in 1836. By 1853, Bowditch was able to write a lengthy treatise on diaphragmatic hernia and included the 27 references present in the literature at that time.1 In 1926, Akerlund, introducing his now-famous classification of hiatus hernia, included short esophagus as his third type. Since, the occurrence of short esophagus and hiatus hernia have been often discussed. The presence of an associated esophageal or gastric carcinoma, at first thought to be rare, has

One of the most perplexing complications of otherwise successful gastric surgery is the development of a complex of gastrointestinal and vasomotor symptoms commonly referred to as the dumping syndrome. Although not fatal, the severity of symptoms may be so great that the patient cannot lead a normal life and in some instances may be unable to continue his usual occupation. The reported incidence of the dumping syndrome following gastrectomy ranges as high as 70% or 80% in various series but is ordinarily significant in only 5% to 12% of patients. The voluminous work on the subject since its first description by Denechau in 1907 attests to its importance and the difficulty of adequate explanation of the symptom complex.Attempts to treat such patients are frustrating for the physician and discouraging to the patient who sometimes thinks that he has traded a benign disease with a specific treatment for a disabling

Patients with completely occluded internal carotid arteries are ordinarily not considered to be candidates for carotid reconstructive surgery. This paper, however, demonstrates the rich anatomical collaterals between the external and internal carotid arteries that become more prominent with internal carotid occlusion. Stenosis of the external carotid in accompaniment with internal carotid occlusion thus becomes a significant lesion.We have operated on 45 such patients in whom the primary therapeutic procedure was endarterectomy of the external carotid. Additional intracerebral blood flow achieved by opening the external carotid in these patients has resulted in significant beneficial clinical effects. A widely patent external carotid can contribute to increased cerebral flow in the presence of various patterns of intracranial and extracranial occlusive disease.

Endarterectomy is preferred by the authors rather than bypass grafting for occlusive disease of the aortoiliofemoral arteries in good risk patients. The eversion technique of endarterectomy permits complete direct vision disobliteration of inaccessible vessels such as the external iliac arteries.A modification of the authors' original technique of eversion endarterectomy for occlusive disease of the aortoiliofemoral arteries is described and illustrated in the text. It consists of conventional endarterectomy of the terminal aorta and common iliac arteries, with transection of the common femoral arteries and their retraction into the abdominal cavity. Eversion endarterectomy of the external iliac and common femoral arteries is performed, after which the treated arteries are replaced beneath the inguinal ligaments and reanastomosed.

Carotid-to-subclavian bypass grafts are frequently employed to treat the subclavian steal syndrome. This laboratory study evaluated the effects on carotid blood flow of varying vascular resistance in the carotid and axillary arteries. In the presence of a functioning carotid-axillary bypass graft, distal carotid blood flow decreased whenever resistance to flow in the distal carotid artery was increased or when resistance in the axillary artery was decreased.These observations explain the mechanism responsible for the occasional failure of a patient to improve following carotid-subclavian bypass grafting. As shown by these experiments, distal obstruction in the carotid artery can result in stealing of blood from the cerebral circulation by carotid-tosubclavian bypass. These studies indicate that obstructing lesions of the carotid artery must be repaired at the time of carotid-subclavian bypass.

Two hundred and thirty-five patients over 60 years of age underwent operation for peptic ulcer disease. Overall mortality was 16%. Mortality increased with age, with site of ulcer, and with amount of preoperative bleeding. The primary surgical procedure had little influence on mortality. Subtotal gastrectomy was more successful than vagotomy and drainage when reoperation was required. There was a high initial mortality with suture ligature and a high recurrence rate with closure of perforation. The cause of death was recurrent hemorrhage or anastomotic leak in 24% of patients, cardiopulmonary failure in 44%, prolonged hypotension in 16%, stroke in 8%, and hepatic failure in 8%. Of 195 patients surviving operation, 75% were alive after one year and 50% were alive four years later. Only 10% of the subsequent deaths were related to ulcer disease.

In 1966, we1 first employed eversion endarterectomy for advanced obstructive disease of the aortoiliofemoral arteries. This technique consists of totally excising various portions of the aortoiliofemoral tree ranging from a single external iliac artery to the entire tree. After excision of the involved vessels, the outer or adventitial layer of the specimen is everted and pulled free of the central diseased core, which is then discarded. The residual media remaining on the everted adventitia is removed with a Freer dissector. The smooth, soft vessel is then inverted right side out and resutured into its normal position in the body. Flow may then be reestablished in the hypogastric vessels, as well as to the superficial and profunda femoris arteries.The final result of this procedure is the same as conventional endarterectomy except that by excising the vessel and performing the endarterectomy by eversion, two advantages are evident: thorough endarterectomy can

Duodenal diverticula are not rare. With the exception of the colon, the duodenum is the most common site of enteric diverticula.1,2 Duodenal diverticula occur in about 1% to 2% of the human population,2,3 but seldom become symptomatic.4,5 Of those who do develop symptoms, only 1% to 5% require surgery.4-7 Symptomatic cases usually are associated with other gastrointestinal disease which must be eliminated as the cause of symptoms.2,5,8Surgeons are becoming more aware of the serious complications associated with duodenal diverticula.9 Of all the complications, perforation is the most serious.1,10 and, fortunately, the rarest.11 Perforation due to enteroliths is the rarest of all.11 It is even rarer to make the preoperative x-ray diagnosis of a perforation; therefore, most perforations have been accidentally found at laparotomy for associated acute gastrointestinal disease.Difficulties in preoperative x-ray diagnosis of perforation are due, in part, to

Although the existence of abdominal angina as a clinical entity distinct from angina pectoris was proposed in the early 1900's,1 it was not generally accepted even as late as 1931 that intraabdominal pain of vascular origin could occur in the absence of gangrene or peritonitis.2 In 1936, Dunphy3 reported seven patients in whom recurrent attacks of abdominal pain preceded the development of fatal mesenteric occlusion and emphasized the importance of recognizing that transient abdominal pain could result from intestinal ischemia. Mikkelsen,4 in 1957, postulated that abdominal angina could be cured, and intestinal infarction prevented by reestablishing flow through the diseased mesenteric vessels. The advisability of surgical correction of these vascular lesions is now generally accepted.Atherosclerosis is the most common cause of chronic ischemia to the alimentary tract.5 It is generally believed that as long as the occlusive process is a gradual one, two of

In 25 dogs ascending aorta-coronary bypass techniques were compared by use of femoral arteries in seven, internal mammary arteries in six, and reversed saphenous veins in twelve. In those animals available for long-term studies the veins were open in eight out of nine, the femoral artery grafts were open in one of four, and the internal mammary arteries were open in two of five. Histologic studies confirmed the adequacy or superiority of the vein grafts. Other conclusions drawn from these experiments were (1) that the saphenous vein bypass should originate from the ascending aorta; (2) that each bypass should have a separate aortic origin; (3) that an arrested quiet heart by means of extracorporeal circulation is necessary for satisfactory distal vein-coronary artery anastomosis; and (4) that the heart is best protected during arrest with ice slush.

A surgical technique (parasternal mediastinotomy) has been described which, with modifications, provides direct access to structures within the mediastinum. The procedure carries little risk for the patient and can be accomplished without disturbing pulmonary function or producing serious discomfort for the patient. We have utilized this technique in a total 152 patients for the diagnosis of indeterminate pulmonary lesions, evaluation of resectability of pulmonary neoplasms, biopsy of mediastinal structures including the heart, and insertion of permanent epicardial electrodes. Anterior mediastinotomy avoids the risks of formal thoracotomy and is of particular value in the treatment of poor risk patients. The use of this approach for placement of epicardial electrodes seems to have advantages over both the transthoracic and transvenous methods of permanent pacemaker implantation.