Delayed primary repair of intrathoracic esophageal perforation: is it safe?

The management of intrathoracic esophageal perforation with delayed diagnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with esophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%). Group A patients were older (p < 0.05) and group B had fewer iatrogenic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patients, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not significant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyzed. Group A had the lowest proportion of postoperative leaks (A, 0/4 patients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of leak and morbidity did not lead to an increase in mortality. One death occurred in each group, with an overall mortality of 17% (A, 1/5 patients, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significant). We conclude that in the era of advanced intensive care capabilities, primary repair of intrathoracic esophageal perforation can be safely accomplished in most patients regardless of the time interval between perforation and operation. Leakage at the suture site is common unless primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result in an adverse outcome.

Popliteal artery trauma: update and recent advances in management.

Management of vascular trauma has been standardized in the past two decades with a significant increase in limb salvage, but trauma to the popliteal artery still remains a challenge. A seven-year experience at San Bernardino County Medical Center was comprised of 20 popliteal artery injuries in 19 patients. Thirteen injuries (65%) were from blunt trauma, four injuries (20%) were from gunshot wounds, two injuries (10%) were from close-range shotgun blasts, and one (5%) was from a stab wound. Limb salvage was 100%. Liberal use of vein interposition grafts, routine intraoperative postreconstructive arteriogram, recognition of compartmental hypertension, and performance of fasciotomy were important steps taken to ensure a high limb salvage rate. Our standard technique at this time consists of repair of the artery with simultaneous repair of the dislocated knee and internal fixation of fractures.

Selective hepatic artery embolization as an adjunct to liver packing in severe hepatic trauma: case report.

Two cases of severe hepatic injury in which bleeding continued despite liver packing are presented. Superselective hepatic artery embolization was used to control the remaining hemorrhage. Embolization is a useful adjunct to liver packing that will decrease mortality in severe hepatic trauma.

Cytochrome o as a terminal oxidase and receptor for aerotaxis in Salmonella typhimurium.

Cytochrome o was the only oxidase of the electron transport system that was present in exponentially growing Salmonella typhimurium ST1. Identification of cytochrome o was made by the (CO-reduced)-minus-(reduced) difference spectra and by the photochemical action spectrum of the relief, by light, of CO-inhibited respiration. Cytochrome o also functioned as the receptor for chemotaxis to oxygen (aerotaxis). The concentration of oxygen that elicits the maximum response for aerotaxis (0.7 microM) was similar to the Km for respiration (0.74 microM), and both aerotaxis and respiration were blocked 5 mM KCN.

Bullet fragment venous embolus to the heart: case report.

This report describes a case of bullet fragment embolus to the heart following a small-caliber gunshot wound to the mouth. Skull and C-spine films appeared to account for the projectile; however, chest X-ray followed by fluoroscopy and two-dimensional echocardiography demonstrated a venous missile embolus in the right heart. The bullet was palpated, trapped in the right ventricle, and easily extruded.

Nitrendipine and superoxide dismutase in ischemic renal injury.

The effect of the Ca entry blocker nitrendipine, the antioxidant superoxide dismutase (SOD), and a combination of nitrendipine and superoxide dismutase on postischemic renal function was studied in four groups (n = 24) of rats. The rats in group 1 (n = 6) were the ischemic control and received 10 mL of 0.9% NaCl. Group II (n = 6) received SOD 7.0 mg/kg. Group III (n = 6) received nitrendipine 1 mg/kg. Group IV (n = 6) received nitrendipine 1 mg/kg and SOD 7 mg/kg. After administration, both kidneys were rendered ischemic by cross-clamping the renal vessels for 60 min. Comparison of 24-h creatinine clearance (CCr) for 3 days after reversal of ischemia revealed: (a) nitrendipine alone was the most effective in preserving renal function (p < .05); (b) SOD provided some degree of improvement, but only on day 3 (p < .05); (c) a similar result was detected using a combination of nitrendipine and SOD (p < .05); (d) there was no significant difference between SOD and nitrendipine nor between SOD and the combination of nitrendipine/SOD; (e) there was a significant improvement with nitrendipine when compared to the combination of nitrendipine/SOD (p < .05).

Effect of calcium entry blocker nitrendipine on renal function after renal vascular occlusion.

The ability of the Ca entry blocker nitrendipine to improve postischemic renal function was studied in nine groups (n = 70) of rats. After anesthesia, nitrendipine was administered for 15 min through the femoral vein. The dose administered depended on the group. Group 1 (n = 7), the control, received only 0.9% NaCl, group 2 (n = 12) 0.25 mg/kg; group 3 (n = 10) 0.50 mg/kg; group 4 (n = 8) 0.75 mg/kg; group 5 (n = 6) 1.00 mg/kg; group 6 (n = 7) 1.50 mg/kg; group 7 (n = 7) 2.00 mg/kg; group 8 (n = 6) 2.50 mg/kg; and group 9 (n = 7) 3.00 mg/kg. After the administration of nitrendipine, the kidneys were rendered ischemic for one hour by cross-clamping the renal vessels. Comparison of 24-h creatinine clearances for 72 h after reversal of ischemia demonstrated that nitrendipine was capable of providing a degree of protection against renal ischemia and the protective effect was dose dependent (p less than .05).