Timing of radiotherapy (RT) after radical prostatectomy (RP): long-term outcomes in the RADICALS-RT trial (NCT00541047).

BACKGROUND: The optimal timing of radiotherapy (RT) after radical prostatectomy for prostate cancer has been uncertain. RADICALS-RT compared efficacy and safety of adjuvant RT versus an observation policy with salvage RT for prostate-specific antigen (PSA) failure. PATIENTS AND METHODS: RADICALS-RT was a randomised controlled trial enrolling patients with ≥1 risk factor (pT3/4, Gleason 7-10, positive margins, preoperative PSA≥10 ng/ml) for recurrence after radical prostatectomy. Patients were randomised 1:1 to adjuvant RT ('Adjuvant-RT') or an observation policy with salvage RT for PSA failure ('Salvage-RT') defined as PSA≥0.1 ng/ml or three consecutive rises. Stratification factors were Gleason score, margin status, planned RT schedule (52.5 Gy/20 fractions or 66 Gy/33 fractions) and treatment centre. The primary outcome measure was freedom-from-distant-metastasis (FFDM), designed with 80% power to detect an improvement from 90% with Salvage-RT (control) to 95% at 10 years with Adjuvant-RT. Secondary outcome measures were biochemical progression-free survival, freedom from non-protocol hormone therapy, safety and patient-reported outcomes. Standard survival analysis methods were used; hazard ratio (HR)<1 favours Adjuvant-RT. RESULTS: Between October 2007 and December 2016, 1396 participants from UK, Denmark, Canada and Ireland were randomised: 699 Salvage-RT, 697 Adjuvant-RT. Allocated groups were balanced with a median age of 65 years. Ninety-three percent (649/697) Adjuvant-RT reported RT within 6 months after randomisation; 39% (270/699) Salvage-RT reported RT during follow-up. Median follow-up was 7.8 years. With 80 distant metastasis events, 10-year FFDM was 93% for Adjuvant-RT and 90% for Salvage-RT: HR=0.68 [95% confidence interval (CI) 0.43-1.07, P=0.095]. Of 109 deaths, 17 were due to prostate cancer. Overall survival was not improved (HR=0.980, 95% CI 0.667-1.440, P=0.917). Adjuvant-RT reported worse urinary and faecal incontinence 1 year after randomisation (P=0.001); faecal incontinence remained significant after 10 years (P=0.017). CONCLUSION: Long-term results from RADICALS-RT confirm adjuvant RT after radical prostatectomy increases the risk of urinary and bowel morbidity, but does not meaningfully improve disease control. An observation policy with salvage RT for PSA failure should be the current standard after radical prostatectomy. TRIAL IDENTIFICATION: RADICALS, RADICALS-RT, ISRCTN40814031, NCT00541047.

In vitro and in vivo evaluation of Dideco's paediatric cardiopulmonary circuit for neonates weighing less than five kilograms.

The neonate cardiopulmonary bypass (CPB) circuit, including a KIDS D100 oxygenator (The Sorin Group, Mirandola, Italy) and a D130 arterial filter (The Sorin Group), was evaluated in vitro with respect to the removal of free micro gas bubbles. No gas bubbles > 40microm were measured after the arterial filter D130 upon manual introduction of 10 ml of air into the venous line or during the use of vacuum-assisted venous drainage (VAVD). The D130 arterial filter removed 88 % of gas bubbles < 40 microm during manual introduction of air into the venous line; however, only 50 % of gas bubbles < 40 microm were removed during the use of VAVD. The same CPB circuit was evaluated in vivo to compare with another CPB circuit, including a D901 oxygenator (The Sorin Group) and arterial filter D736 (The Sorin Group), in 155 neonates weighing < or =5 kg. The D100 circuit required significantly less priming volume than the D901 circuit. Postoperative haemoglobin was significantly higher, artificial ventilation time was significantly shorter and postoperative bleeding was significantly less in the D100 group. This neonate CPB circuit effectively removed the gas bubbles and required up to 37% less priming volume and, thus, decreased the need for blood transfusion.

Assessment of hospital surge capacity using the MACSIM simulation system: a pilot study.

AIM: The aim of this study was to use a simulation model developed for the scientific evaluation of methodology in disaster medicine to test surge capacity (SC) in a major hospital responding to a simulated major incident with a scenario copied from a real incident. METHODS: The tested hospital was illustrated on a system of magnetic boards, where available resources, staff, and patients treated in the hospital at the time of the test were illustrated. Casualties were illustrated with simulation cards supplying all data required to determine procedures for diagnosis and treatment, which all were connected to real consumption of time and resources. RESULTS: The first capacity-limiting factor was the number of resuscitation teams that could work parallel in the emergency department (ED). This made it necessary to refer severely injured to other hospitals. At this time, surgery (OR) and intensive care (ICU) had considerable remaining capacity. Thus, the reception of casualties could be restarted when the ED had been cleared. The next limiting factor was lack of ventilators in the ICU, which permanently set the limit for SC. At this time, there was still residual OR capacity. With access to more ventilators, the full surgical capacity of the hospital could have been utilized. CONCLUSIONS: The tested model was evaluated as an accurate tool to determine SC. The results illustrate that SC cannot be determined by testing one single function in the hospital, since all functions interact with each other and different functions can be identified as limiting factors at different times during the response.

Ultrafiltration after cardiopulmonary bypass in children: effects on hemodynamics, cytokines and complement.

OBJECTIVES: The purpose of the study was to evaluate the clinical and hemodynamic effect of intraoperative extracorporeal ultrafiltration (UF) and its potential in reducing the plasma concentration of circulating cytokines and complement activation products following open heart surgery in children. METHODS: Eighteen children with congenital heart disease were prospectively randomized into a control group (n = 9) and a group who underwent UF (n = 9). Serial plasma samples for measurements of circulating cytokines (interleukin 6 (IL-6), tumor necrosis factor alpha (TNF), and its soluble receptor (sTNF receptor)), and complement factors (C3 activation products (C3a and C3bc) and terminal complement complex (TCC)) were obtained before, during and up to 48 h after cardiopulmonary bypass (CPB). A pulmonary artery thermodilution catheter was introduced preoperatively for hemodynamic monitoring. RESULTS: Postoperative hemodynamics were similar in both groups. Plasma levels of IL-6, sTNF receptors, C3a, C3bc and TCC increased significantly perioperatively (P < 0.01) in both groups. TNF was detected transiently in 16 patients perioperatively and in 4 of the 9 ultrafiltrate samples in concentrations similar to the plasma levels. Complement activating products were not detected in the ultrafiltration samples except for small amounts of C3a in two cases. Compared to the control group the plasma levels of C3a, C3bc and TCC were unaffected by the ultrafiltration procedure. The level of IL-6 and sTNF receptors increased significantly after 15 min of UF but there was no significant difference between the two groups postoperatively. CONCLUSIONS: In this study no clinical or hemodynamic effect was registered after UF. TNF and C3a were occasionally detected in the ultrafiltrate but we were unable to demonstrate reduction of these or any of the other markers tested in the group subjected to ultrafiltration.

Education, smoking and non-cardiovascular mortality: findings in three Chicago epidemiological studies.

The interrelationships among education, smoking, and non-cardiovascular (non-CVD) mortality were examined in middle-aged white males from the Chicago Peoples Gas Company Study (PG), the Chicago Western Electric Company Study (WE), and the Chicago Heart Association Detection Project in Industry (CHA). In each study, college graduates had the lowest prevalence of current smokers and the highest prevalence of former smokers. The associations between education and smoking were strongest in CHA, a study with baseline measurements 10-14 years after those of PG and WE and 3-8 years after the US Surgeon General's report on smoking and health in 1964. In PG and WE, the relative risks of non-CVD death for those who did not attend college compared to those who did were 1.50 and 1.38 (95% limits, 1.04 to 2.18 and 0.95 to 2.02). In CHA, the relative risk for those who did not graduate from college compared to those who did was 1.55 (1.17, 2.05). Differences in baseline cigarette smoking could account for only 23-29% of these increased risks. Because the associations between education and non-CVD mortality may have been confounded by changes in smoking status over the course of follow-up in these studies, non-CVD deaths were subdivided into those from causes related to smoking and causes not related to smoking. For smoking-related causes, the relative risk of death for those who did not attend/graduate from college was 1.95 (0.96, 3.95) in WE, 2.13 (1.18, 3.87) in PG, and 2.34 (1.47, 3.84) in CHA, while the relative risks for causes not related to smoking were 1.17, 1.12 and 1.16, respectively. These findings suggest that education is related inversely to non-CVD mortality primarily through smoking and smoking-related causes of death. With smoking becoming increasingly a habit of the less well-educated, these findings underscore the need for smoking prevention and cessation programmes targeted at the lower end of the socioeconomic scale.

Surgical elimination of an atrial septal aneurysm causing cerebral embolism.

Atrial septal aneurysms have been recognized as sources of arterial embolism. An intraatrial aneurysm was demonstrated in the fossa ovalis of a 45-year-old woman who suffered an episode of cerebral embolism. The disorder is rarely treated surgically. Most patients with this condition are given life-long anticoagulation, a treatment that may have serious complications. As an alternative treatment with possible lower risk, we removed the aneurysm surgically.

Should the lungs be ventilated during cardiopulmonary bypass? Clinical, hemodynamic, and metabolic changes in patients undergoing elective coronary artery surgery.

No beneficial effects were achieved by ventilating the lungs of a group of 10 patients during total extracorporeal circulation for coronary artery bypass operation. Ventilation of nonperfused lungs, which was suggested to prevent postoperative atelectasis, may even have negative effects. Intrapulmonary shunting increased significantly (p less than 0.05), while the shunt fraction in the nonventilated lungs of another group of 10 patients remained unchanged. There were only minor differences between the two groups with respect to systemic and pulmonary hemodynamic changes.

Some observations on cerebral perfusion during cardiopulmonary bypass.

Blood flow was recorded with an electromagnetic flow probe on one internal carotid artery (ICA) during cardiopulmonary bypass (CPB) in 5 patients. The ICA flow was monitored continuously along with arterial blood pressure, epidural intracranial pressure, and cerebral electrical activity using a cerebral function monitor (3 patients). The ICA flow increased by 50 to 100% at the inception of extracorporeal circulation. This rapid enhancement of flow occurred within a thirty-second period and was due to rapid arterial hemodilution caused by introduction of the priming solution. A transitory fall in ICA flow was observed during subsequent minutes when the well-recognized drop in blood pressure took place and the cerebral perfusion pressure (CPP = blood pressure - epidural intracranial pressure) was reduced to less than 30 mm Hg. In only one instance, however, when CPP fell to 15 mm Hg, was the fall in flow lower than the prebypass level. Throughout the rest of CPB, with steady-state hemodilution and CPP levels in the range of 30 to 50 mm Hg, ICA flow was markedly enhanced (50 to 100% above the prebypass level). The flow pattern, however, disclosed a pressure-passive system, indicating that cerebral autoregulation was impaired or that the CPP levels were lower than the individual lower limit of cerebral autoregulation during the period of steady-state hemodilution on CPB. A transient depression of cerebral electrical activity was seen in 2 patients shortly after the introduction of CPB. This phenomenon is suggestive of qualitatively insufficient perfusion and was observed even when ICA bulk flow was increased (hematocrit values, 13 to 17%).

A pharmacokinetic study of dalteparin (Fragmin) during late pregnancy.

Seventeen women with previously verified thromboembolism were included in a pharmacokinetic evaluation of dalteparin during the third trimester of pregnancy. The bioavailability of morning subcutaneous administration of dalteparin (crossover study) was also compared with that in the evening. Fifteen women injected themselves subcutaneously with 5000 IU and two with 2500 IU dalteparin once daily. An anti-FXa activity of 0.20-0.40 IU/ml 3 h after injection was obtained. The means +/- SD, when comparing morning and evening doses for 5000 IU, were: Cmax 0.21 +/- 0.05 and 0.20 +/- 0.05 IU anti-FXa/ml, AUC 0-24 h 1.97 +/- 0.46 and 1.93 +/- 0.55 IU x h/ml and tmax 3.71 +/- 0.89 and 4.32 +/- 1.60 h, respectively (NS). The two regimens were equivalent. A measurable anticoagulant effect was still observed 16 h after injection of 5000 IU dalteparin. The half-lives after a morning and an evening dose of 5000 IU dalteparin were 4.92 +/- 2.80 and 3.87 +/- 1.15 h, respectively (NS). There were no changes in thrombin marker levels during the two pharmacokinetic measurements.

Thromboprophylaxis with low molecular mass heparin, 'Fragmin' (dalteparin), during pregnancy--a longitudinal safety study.

Twenty-five women with previous verified thromboembolic complications were treated with delteparin (Fragmin) during pregnancy and puerperium. Women with known hereditary thrombophilia (antithrombin, protein C and protein S deficiencies) or with phospholipid antibodies were excluded. The dose at entry was calculated according to body weight and thereafter monitored by anti-FXa activity aiming at 0.20-0.40 IU/ml plasma 3 h post injection. Dalteparin or dextran was used during delivery. Twenty-two women completed the study and 14 of these could be given the same dose throughout pregnancy. There was an increased dose response postpartum. There were no thromboembolic recurrences or severe bleeding complications. The level of antithrombin activity remained normal. Our thrombosis-prone pregnant women had initially increased levels of thrombin markers but no further increase was observed during the dalteparin thromboprophylaxis. Retrospectively, three heterozygous and three homozygous individuals for the FV Leiden mutation leading to activated protein C resistance were identified. In conclusion, dalteparin could safely be used as thromboprophylaxis during pregnancy in these thrombosis-prone women. Women weighing 50-79 kg at entry could be treated with 5000 IU of dalteparin once daily during pregnancy, without monitoring. Postpartum, many of the women were given a reduced dose.

Mechanical valve replacement in congenital heart disease.

BACKGROUND AND AIMS OF THE STUDY: Mechanical valves are the prosthesis of choice in valve replacement in children. However, the problem of somatic growth leading to patient-valve mismatch remains present, and the appropriate anticoagulation regimen remains controversial. We present our experience of valve replacement in a young population over 20 years. MATERIALS AND METHODS: Between 1972 and 1992, 48 patients (34 males and 14 females), mean age 11.2 years (range 0.4-27.4 years), underwent mechanical valve replacement at our institution. Aortic valve replacement was performed in 28 patients (58.3%), mitral valve replacement in 13 (27.1%), tricuspid valve replacement in six (12.5%) and pulmonary valve replacement in one patient (2.1%). The prostheses used were: St. Jude Medical (n = 2), Björk-Shiley (n = 14), Medtronic Hall (n = 16), Duromedics (n = 2) and CarboMedics (n = 14). Early mortality was 14.3%, 10.7% for aortic valve replacement and 30.8% for mitral valve replacement. Mean follow up for all patients was 8.3 years (range 0-22 years), with a total of 398 patient-years. RESULTS: Seven patients died during the follow up (17.1%). Survival after 10 years, including operative mortality, was 81% for aortic valve replacement, 33% for mitral valve replacement, 83% for tricuspid valve replacement and 100% for pulmonary valve replacement. All patients were anticoagulated with warfarin. In eight patients (16.7%) an antiplatelet drug (aspirin or dipyridamole) was added. Major events included paravalvular leak in six patients (1.5%/pty), valve thrombosis in five (mitral position in two, tricuspid in three) (1.3%/pty) and endocarditis in one patient (0.3%/pty). Minor thromboembolic events occurred in three patients (0.8%/pty) and minor hemorrhagic events in three (0.8%/pty). No patients developed hemolytic anemia and there was no case of structural failure. CONCLUSIONS: In our experience, mechanical prostheses in congenital heart disease were associated with significant morbidity and mortality, however long term survival after aortic valve replacement was good (81% at 10 years). Thromboembolic and hemorrhagic events were of minor significance. Atrio-ventricular valve replacement carried the highest risk of valve thrombosis and we now give warfarin and an antiplatelet drug to children undergoing mechanical valve implantation in this position.

The increase of body iron stores estimated by the increase of serum ferritin concentration during ferrous sulphate treatment after gastrointestinal surgery.

A 6-wk period of iron therapy with ferrous sulphate (80 mg Fe++ three times daily) was given to 16 males and 16 females on whom previously various common gastrointestinal surgery had been performed and who had empty iron stores estimated from low serum ferritin concentration. The results were compared with a control group corresponding to the study group in respect to sex, number of patients, primary disease, previous operation, and the empty iron stores. The iron therapy replenished the empty body iron stores, because the serum ferritin concentrations increased from 11 +/- 7 to 35 +/ 13 micrograms/liter (p less than 0.001) in the males and from 9 +/- 6 to 30 +/- 10 micrograms/liter (p less than 0.001) in the females, whereas the corresponding changes in the control group were from 10 +/- 9 to 11 +/- 8 micrograms/liter and from 11 +/- 8 to 13 +/- 11 micrograms/liter in the males and females, respectively. Also the blood hemoglobin concentration increased in the group receiving iron from 136 +/- 11 to 150 +/- 11 g/liter (p less than 0.01) and from 130 +/- 12 to 142 +/- 11 g/liter (p less than 0.01) and the serum iron from 14 +/- 6 to 18 +/- 5 mmol/liter (p less than 0.01) and from 13 +/- 6 to 17 +/- 6 mmol/liter (p less than 0.01) in males and females, respectively, whereas corresponding changes in the control group for hemoglobin were from 135 +/- 10 to 137 +/- 11 g/liter and from 129 +/- 11 to 131 +/- 10 g/liter and for serum iron from 14 +/- 6 to 14 +/- 5 mmol/liter and from 14 +/- 6 to 14 +/- 5 mmol/liter, in the males and females, respectively. The response to iron treatment varied considerably between different patients, because in some few patients serum ferritin decreased during the study and in some the increase was several-fold the initial value. The study shows that ferrous sulphate treatment is an effective and practical way to replenish the empty iron stores, estimated from serum ferritin concentrations, in patients after various gastrointestinal surgery and that concomitantly the blood hemoglobin and serum iron concentrations will increase.

Congenital pulmonary arteriovenous fistula.

Pulmonary arteriovenous fistula wherein the malformation has venous drainage directly to the left atrium is a rare anomaly. Two case reports present such unusual arteriovenous malformations successfully treated by surgery.

Experiences with closed chest, temporary atrio-arterial, ventricular bypass with a centrifugal pump after open heart surgery.

Twelve patients with refractory myocardial failure following open heart surgery were treated with a temporary left (10), right (1) or biventricular (1) assist circuits driven by extracorporeal pumps. Ten of 11 patients were weaned from the pump oxygenator. During left ventricular assist, maximal pump flow was 2.2 +/- 0.6 l/min per m2 at a cardiac index of 2.5 +/- 0.9 l/min per m2. Diuresis was above 1 ml/kg body weight per h in 7 of 9 patients perfused for 13-36 h. Seven patients were weaned from the assist pump after 13-33 h of ventricular bypass with 4 hospital survivors. Two patients died after circulatory assistance of multiple organ failure, 1 from cerebral damage. In the other patients, the main problems were cardiac. Three patients are currently long term survivors 12-17 months after surgery.

Senning operation for transposition of the great arteries in the first month of life.

Twelve patients with uncomplicated transposition of the great arteries were operated upon in the first month of life following an initial Rashkind procedure. They were all in a clinically unacceptable condition and were mostly acidotic or bad mixers without acidosis. Two patients died postoperatively from a cerebral haemorrhage not discovered prior to operation. One patient died 5 months postoperatively from bronchiolitis. At postoperative follow-up, all patients were asymptomatic. Cardiac catheterization showed that 1 patient had a significant upper caval vein stenosis, 2 patients had small atrial shunts, and 1 patient had an unimportant pulmonary stenosis. Innocent atrial rhythm disturbances were encountered in 1 case only, whereas 9 patients had normal sinus rhythm at the last examination. The Senning operation remains a good alternative for transposition repair in the neonate.

Risk factors for total and cause-specific mortality in human cardiac transplantation. Prolonged extracorporeal bypass time: a high risk factor for rejection and infection.

Data from the first 103 human heart transplantations in 100 recipients performed at a single centre from November 1983 to January 1990 were analysed to detect risk factors for overall and cause-specific mortality. Twenty-two patients died. Cumulative 1 year graft survival was 82% and 5 year, 68%. Acute and chronic rejection was the cause of death in 9 patients, disseminated infection in 8 and cancer in 3. One patient died from cerebral haemorrhage and 1 from acute cardiac failure. The mean observation time was 803 days (range: 1-2 308 days). Total follow-up was 226.6 graft years. Risk factors were analysed by univariate and multivariate methods. The type of immunosuppression regimen and recipient age above 50 years were independent risk factors for mortality. Histocompatibility mismatching (HLA-DR) and type of immunosuppression were independent risk factors for lethal rejection and a female recipient was an independent risk factor for lethal infection. Prolonged time on extracorporeal bypass was an independent risk factor for both lethal rejection and infection, and also for overall mortality. The impact of extracorporeal bypass time on rejection and infection is discussed, and the importance of prospective HLA matching in heart transplantation is stressed. The association between recipient female sex and infection remains uncertain.

Ascorbic acid does not augment the restoration effect of iron treatment for empty iron stores in patients after gastrointestinal surgery.

The effect of a 6-week combined treatment with ferrous sulfate (80 mg Fe++ three times daily) and ascorbic acid (75 mg three times daily) on the empty iron stores in 20 patients after gastrointestinal surgery was examined from changes of serum ferritin. One group of 20 patients with similar clinical characteristics served as controls. The treatment replaced the empty iron stores. Since mean serum ferritin concentrations increased from 9 +/- 8 to 29 +/- 11 micrograms/l (P less than 0.001) in males and from 8 +/- 8 to 26 +/- 10 micrograms/l (P less than 0.001) in the females. Also blood hemoglobin and serum iron concentrations increased significantly (P less than 0.01). Among the controls there were no marked changes in serum ferritin, blood hemoglobin or serum iron concentrations. However, the increase of serum ferritin caused by this combined treatment was similar with that caused previously by pure ferrous sulfate treatment. Thus, it is considered that the combined treatment with ferrous sulfate (80 mg Fe++ three times daily) and ascorbic acid (75 mg three times daily) restores the empty iron stores in patients after gastrointestinal surgery, but that the increase is not augmented by the ascorbic acid. Thus, a pure iron therapy is recommended to fill up the empty iron stores in these patients.

The prevalence of gonarthrosis and its relation to meniscectomy in former soccer players.

The prevalence of radiographic signs of gonarthrosis and its relation to knee injuries were studied in 286 former soccer players--215 nonelite and 71 elite players--and were compared with 572 age-matched controls with a mean age of 55 years. The prevalence of gonarthrosis among the nonelite players was 4.2%, among the elite players 15.5%, and among the controls 1.6%. Seven of the soccer players had known anterior cruciate ligament injuries, and 40 had had meniscectomies. Of the 32 nonelite players with knee injuries, 4 (13%) had gonarthrosis, and of the 183 without known knee injuries 5 (3%) had gonarthrosis. Among the elite players, the prevalence of gonarthrosis in knees without diagnosed injuries was 11%. We conclude that soccer, especially at an advanced level, is associated with an increased risk for gonarthrosis. After excluding subjects with known knee injuries, there was no difference between nonelite players and controls, but we found a higher rate of gonarthrosis among the elite players.

Metabonomics, dietary influences and cultural differences: a 1H NMR-based study of urine samples obtained from healthy British and Swedish subjects.

The aim of this study was to assess the feasibility and comparability of metabonomic data in clinical studies conducted in different countries without dietary restriction. A (1)H NMR-based metabonomic analysis was performed on urine samples obtained from two separate studies, both including male and female subjects. The first was on a group of healthy British subjects (n = 120), whilst the second was on healthy subjects from two European countries (Britain and Sweden, n = 30). The subjects were asked to provide single, early morning urine samples collected on a single occasion. The (1)H NMR spectra obtained for urine samples were visually inspected and analysed chemometrically using principal components analysis (PCA). These inspections highlighted outliers within the urine samples and displayed interesting differences, revealing characteristic dietary and cultural features between the subjects of both countries, such as high trimethylamine-N-oxide (TMAO)-excretion in the Swedish population and high taurine-excretion, due to the Atkins diet. This study suggests that the endogenous urinary profile is subject to distinct cultural and severe dietary influences and that great care needs to be taken in the interpretation of 'biomarkers of disease and response to drug therapy' for diagnostic purposes.

High serum lactic acid concentration after laparotomy and peritonitis in iron stores depletion. An experimental study on the rat.

Total depletion of iron stores with a moderately decreased blood hemoglobin concentration (114 x 10 vs. 155 x 12 g/l in controls, n = 28) was produced in rats (n = 28) by rearing them for six weeks on an iron free diet, in iron free cages, starting at two weeks of age. The controls were treated at the same time in same conditions, except that they were given a normal supply of dietary iron. In all rats laparotomy and peritonitis by ligation and puncture of the caecum were carried out with ether anesthesia. Postoperative mortality and blood lactic acid concentration were followed for 120 minutes after the procedure. Postoperative mortality (8 of 28, 29% vs. 1 of 28, 4%) and blood lactic acid concentration (3.3 x 0.3 to 3.6 x 0.5 vs. 1.4 x 0.1 to 1.8 x 0.2 mmol/l) were higher (p less than 0.001) in the experimental group than in the control animals. The surviving rats (2.0 x 0.1 to 2.1 x 0.2 mmol/l) had a lower (p less than 0.001) blood lactic acid concentration than those who died (5.6 x 0.5 to 6.1 x 1.1). The results suggest that total lack of iron producing a moderate decrease of blood hemoglobin concentration creates a significant risk in abdominal surgery and focus the activation of the anaerobic energy yielding process.