Hiatal hernia complicated by oesophageal stricture. Surgical treatment and results. A follow-up study.

During a 10-year period, 1967-1976, 57 patients were operated upon for hiatal hernia and gastro-oesophageal reflux complicated by oesophageal stricture. Forty-four patients were managed by various surgical antireflux procedures combined with dilation of the stricture. In 12 patients the stricture was resected and the oesophageal continuity restored by oesophagogastrostomy. The primary mortality was 3.5%. Fifty-two patients were carefully followed up postoperatively by periodic control examiniations. The results of the treatment are presented. The main cause of unsatisfactory postoperative results was gastro-oesophageal reflux uncorrected by the surgical procedure. In the patients subjected to a hernia repair the failure of the antireflux procedure was due mainly to a shortened oesophagus associated with the stricture. It is concluded that most of these strictures can be successfully treated by dilation after establishment of control of the pathological reflux by means of an antireflux surgical procedure. The location, width, length and rigidity of the stricture, as revealed at the preoperative examination, are not decisive for the choice of therapeutic approach.

Haemodynamic stability during anaesthesia induction and sternotomy in patients with ischaemic heart disease. A comparison of six anaesthetic techniques.

A comparison of haemodynamic stability with respect to arterial pressure, heart rate and cardiac output between six commonly used anaesthetic techniques: fentanyl (FE), halothane (HAL), morphine (MO), fentanyl/droperidol (NLA), and thiopentone (two dose levels: PE 3 and PE 6), all supplemented with nitrous oxide, was performed during induction of anaesthesia and sternotomy in 47 patients with good left ventricular function and maintained beta-blockers undergoing coronary bypass surgery. Interventions were kept to a minimum in order to characterize each anaesthesia group. Statistically, the material fell into two parts. The MO, PE 3 and PE 6 groups showed good stability under steady-state anaesthesia, but variable and often extensive hyperdynamic responses were seen to endotracheal intubation and surgical stimulation. The FE, HAL and NLA groups were characterized by a good stability during the induction-intubation phase but were unstable when combined with nitrous oxide in the absence of noxious stimuli.

Left ventricular function during anaesthesia induction and sternotomy in patients with ischaemic heart disease. A comparison of six anaesthetic techniques.

A comparison between five anaesthetic procedures, fentanyl (FE), morphine (MO), halothane (HAL), fentanyl/droperidol (NLA) and thiopenthone (two dose levels: PE 3 and PE 6), all supplemented with nitrous oxide, was performed with respect to the left ventricular function (LVF) during anaesthesia induction and sternotomy in 47 patients with good preoperative LVF and maintained beta-blockers. Peroperative LVF was characterized by left ventricular stroke volume (stroke index) and external pressure volume stroke work (left ventricular stroke work index) in relation to filling pressure (pulmonary capillary wedge pressure) and outflow resistance (systemic vascular resistance). The individual patient patterns in each group indicated normal LVF in the awake state. Anaesthesia induction was followed by a moderate depression of LVF in the HAL, MO, PE 3 and PE 6 groups at full dose of anaesthetic agent. After addition of nitrous oxide, there was also a decrease of preload in all groups, masking any additional depressions of LVF. The response to external stimuli, endotracheal intubation and sternotomy was that of mildly depressed LVF in the majority of the patients. The haemodynamic reactions in the FE and NLA groups were more varied. In all groups some patients (approximately 30%) showed signs of left ventricular failing in response to external stimuli. With the exception of the more variable haemodynamic reactions in the FE and NLA groups, the differences between the anaesthesia groups with respect to LVF depended mainly on extracardiac factors.