Pneumoperitoneum and its association with ruptured abdominal viscus.

Pneumoperitoneum is not invariably associated with ruptured or perforated intra-abdominal viscus. To determine the incidence of free air associated with intra-abdominal viscus perforation, the medical records of 77 consecutive patients whose discharge or autopsy diagnosis included pneumoperitoneum or perforated viscus at a community hospital were retrospectively reviewed between June 1980 and October 1985. Abdominal viscus perforation, as determined by contrast studies or at operation, was not invariably associated with free air. Sixty-nine percent (23/33) of gastroduodenal, 30% (3/10) of small-bowel, and 37% (11/30) of large-bowel perforations had free air, as determined by preoperative x-ray film. Four cases with a total of six episodes of pneumoperitoneum were identified where viscus perforation was not documented. Pneumoperitoneum thus remains a reliable sign of viscus perforation; however, lack of this finding does not rule out perforation, and unusual causes must be considered.

Repair of limited or segmental defects of the cervical esophagus with mucosa-lined flaps.

Repair of limited cervical esophageal defects can now be accomplished safely with mucosa-lined flaps. Free jejunal grafts have demonstrated excellent durability and function for circumferential defects. The axial cheek flap and laryngeal flap have also shown excellent functional results for noncircumferential defects. In addition, all three of these procedures offer the advantage of immediate reconstruction. The size of the esophageal defect, the physical condition of the patient, and the rehabilitative goals are critical in patient selection.

Hemilaryngeal reconstruction using an axial island cheek flap supported by Marlex and stainless steel wire mesh.

The defect that remains after an extended hemilaryngectomy continues to be a challenge to the reconstructing surgeon. The reconstruction ideally must provide airway protection against aspiration, allow for phonation, and provide a durable mucosal surface. It also must be accomplished in one stage. Nine Labrador dogs underwent successful reconstruction of the hemilarynx using an axial island cheek flap based on the facial artery and vein. Adequate laryngeal function was demonstrated by maintenance of body weight, normal barium swallows, return of strong bark, and no evidence of aspiration pneumonia. Pathologic review confirmed a viable mucosal surface and incorporation of the Marlex and stainless steel wire mesh in a fibrous reaction. We have concluded that this method of reconstruction provides a result superior to currently used techniques.