Does Mean Platelet Volume Decrease in the presence of Coronary Artery Fistula?

BACKGROUND: Coronary artery fistula (CAF) is an abnormal connection that links a coronary artery to a cardiac chamber or another major blood vessel. Several studies have shown the association between mean platelet volume (MPV) and cardiovascular diseases. In the literature, there is no previous study about the association between hematologic parameters and congenital CAF. For this reason, we aimed to investigate the association of MPV with CAF. METHODS: 70 patients with normal coronary arteries and 50 with coronary artery fistulas were included. Routine blood and biochemical parameters were measured before the arteriography. Differences between groups for continuous variables were analyzed with t- test or Mann-Whitney test. P values < 0.05 were considered significant. Regression analysis was used to find independent predictors of CAF. RESULTS: Baseline patient demographics, including age and clinical risk factors, were similar between the groups. Compared to the control group, median (IQR) High-density lipoprotein cholesterol (HDL) levels were significantly higher (p=0.04) and MPV levels were significantly lower in the CAF group (8.84 ± 1.71fL vs. 10.43 ± 1.34, p < 0.001). In the multivariate analysis, only MPV was a significant predictor of CAF (p < 0.001, 95% CI for OR: 0.438 (0.306-0.629). A negative correlation was found between MPV and fistulae in Pearson's correlation test (r: -0.454, p < 0.001). An MPV level of < 9,6 fL showed sensitivity, specificity, positive predictive value and negative predictive value of 80%, 68%, 71% and 78% respectively (AUC = 0.766, 95% CI, 0.678-0.854) for the prediction of CAF. CONCLUSION: The present study suggests that MPV may decrease in patients with CAF.

Does Mean Platelet Volume Decrease in the presence of Coronary Artery Fistula? / O Volume Médio Plaquetário Diminui na Presença de Fístula da Artéria Coronária?

Abstract Background: Coronary artery fistula (CAF) is an abnormal connection that links a coronary artery to a cardiac chamber or another major blood vessel. Several studies have shown the association between mean platelet volume (MPV) and cardiovascular diseases. In the literature, there is no previous study about the association between hematologic parameters and congenital CAF. For this reason, we aimed to investigate the association of MPV with CAF. Methods: 70 patients with normal coronary arteries and 50 with coronary artery fistulas were included. Routine blood and biochemical parameters were measured before the arteriography. Differences between groups for continuous variables were analyzed with t- test or Mann-Whitney test. P values < 0.05 were considered significant. Regression analysis was used to find independent predictors of CAF. Results: Baseline patient demographics, including age and clinical risk factors, were similar between the groups. Compared to the control group, median (IQR) High-density lipoprotein cholesterol (HDL) levels were significantly higher (p=0.04) and MPV levels were significantly lower in the CAF group (8.84 ± 1.71fL vs. 10.43 ± 1.34, p < 0.001). In the multivariate analysis, only MPV was a significant predictor of CAF (p < 0.001, 95% CI for OR: 0.438 (0.306-0.629). A negative correlation was found between MPV and fistulae in Pearson's correlation test (r: -0.454, p < 0.001). An MPV level of < 9,6 fL showed sensitivity, specificity, positive predictive value and negative predictive value of 80%, 68%, 71% and 78% respectively (AUC = 0.766, 95% CI, 0.678-0.854) for the prediction of CAF. Conclusion: The present study suggests that MPV may decrease in patients with CAF.

Resumo Fundamento: A fístula da artéria coronária (FAC) é uma conexão anormal que liga a artéria coronária a uma câmara cardíaca ou outro importante vaso sanguíneo. Vários estudos mostraram a associação entre o volume plaquetário médio (VPM) e as doenças cardiovasculares. Na literatura, não há estudo prévio sobre a associação entre os parâmetros hematológicos e a FAC congênita. Por essa razão, nosso objetivo foi investigar a relação do VPM com a FAC. Métodos: Foram incluídos 70 pacientes com artérias coronárias normais e 50 com fístulas de artérias coronárias. Os parâmetros sanguíneos e bioquímicos de rotina foram medidos antes da arteriografia. As diferenças entre os grupos para as variáveis contínuas foram analisadas com o teste t ou teste de Mann-Whitney. Valores de p < 0,05 foram considerados significativos. A análise de regressão foi utilizada para encontrar preditores independentes de FAC. Resultados: Os dados demográficos basais dos pacientes, incluindo idade e fatores de risco clínicos, foram semelhantes entre os grupos. Comparados à mediana do grupo controle (IIQ), os níveis de HDL-colesterol foram significativamente mais altos (p = 0,04) e os níveis de VPM foram significativamente mais baixos no grupo FAC (8,84 ± 1,71fL vs. 10,43 ± 1,34, p < 0,001). Na análise multivariada, apenas o VPM foi um preditor significativo de FAC (p<0,001, IC 95% para OR: 0,438 (0,306-0,629)). Foi encontrada uma correlação negativa entre o VPM e fístulas no teste de correlação de Pearson (r: -0,454, p < 0,001). Um nível de VPM < 9,6 fL apresentou sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de 80%, 68%, 71% e 78%, respectivamente (AUC = 0,766, IC 95%, 0,678-0,854) para a previsão de FAC. Conclusão: O presente estudo sugere que o VPM pode diminuir no paciente com FAC.

Neutrophil-to-lymphocyte ratio as a prognostic factor for pharyngocutaneous fistula after total laryngectomy.

SUMMARY: The role of systemic inflammatory response as a prognostic factor has been proposed in a variety of cancers. The purpose of this study was to investigate the prognostic value of the pretreatment neutrophil-to-lymphocyte ratio (NLR) in the incidence of pharyngocutaneous fistula (PCF) in patients who underwent total laryngectomy. We conducted a retrospective cohort analysis of 141 patients with squamous cell carcinoma of larynx who underwent total laryngectomy from 2009 to 2015. The incidence of PCF was 49.6%. A higher risk of 23% was observed among patients with NLR > 2.5 for the occurrence of PCF (p = 0.007). Patients with laryngeal squamous cell carcinoma who present elevated values in the ration > LR> (> 2.5) presented a higher risk of developing pharyngocutaneous fistula in the postoperative setting of total laryngectomy.

Challenges and limitations in the diagnosis of atrioesophageal fistula.

INTRODUCTION: Atrioesophageal fistula (AEF) is a dire complication of atrial fibrillation ablation. The diagnostic yield of computed tomography (CT) chest, the role and timing of repeat testing, and the value of other investigations in the diagnosis of AEF is uncertain. METHODS: We systematically reviewed published AEF cases to evaluate radiological, bedside, and biochemical investigations for AEF (registered on PROSPERO [CRD42017077493]). RESULTS: Eighty-seven articles with 126 patients (median age, 59 years; male, 71%) were included in the analysis. CT chest was performed in 88% (111/126) and was abnormal in 87%. A clear diagnosis of AEF (fistula/perforation) was only detected in 35% (34/97). Other major findings included free air in mediastinum (26%), left atrium (LA), or LA wall (24%). In 11 patients with normal/nonspecific initial CT chest, major abnormalities were detected in 91% (10/11) of repeat CT chest performed 6 days (median; range, 4-22) after initial scan. Initial CT head was normal in 51%; diffuse air emboli was identified in 79% (22/28). Initial transthoracic echocardiography was normal in 61% of cases. The spectrum of radiological abnormalities included Air (mediastinum/LA), Effusion (pleural/pericardial), Fistula/Perforation, and Thickening (esophagus/LA) - "AEF-Tests." Esophagram demonstrated contrast extravasation in 87% (13/15). Blood culture was consistently positive (100%; 28/28), particularly for streptococcus species (93%; 26/28). CONCLUSION: The diagnosis of AEF remains challenging. Clinicians should be aware of the limitations in the yield of CT chest, the variety of major abnormalities reported, the need for repeat testing, unique brain imaging findings, and the importance of positive blood cultures and raised inflammatory markers.

The Risk Factors for Refractory Fistula after Esophagectomy with Gastric Tube Reconstruction in Patients with Esophageal Cancer.

BACKGROUND/AIMS: Anastomotic leakage (AL) after esophagectomy is associated with high rates of postoperative morbidity and mortality. In cases with leakage, a refractory fistula (RF) is sometimes recognized after esophagectomy. The aim of this study was to evaluate the risk factors for RF after esophagectomy with gastric tube reconstruction. METHODS: This study enrolled 244 consecutive esophageal cancer patients who had undergone esophagectomy with gastric tube reconstruction. RF was defined as a noncurative anastomotic site-cutaneous fistula that had been present for more than 2 months. We evaluated the risk factors for RF. RESULTS: AL occurred in 30 patients (12.3%). There was one mortality case (0.4%) due to mediastinitis caused by AL in the present series. A multivariate analysis revealed that the subcutaneous route was an independent risk factor for AL (OR 4.42, 95% CI 1.42-13.8, p = 0.01), and that the subcutaneous route was an independent risk factor for RF (OR 13.30, 95% CI 2.50-71.30, p = 0.0024). CONCLUSION: The results of this retrospective study suggest that subcutaneous route was associated with an increased risk of RF after esophagectomy with gastric tube reconstruction. The preoperative identification of risk factors may contribute to the prevention of postoperative AL and RF.

Complicaciones en cirugia endoscópica de la base de cráneo / Complications of endoscopic skull base surgery

Las complicaciones mayores asociadas a los abordajes endoscópicos no son distintas de las asociadas a los abordajes tradicionales de la base de cráneo. Las más frecuentes son la fístula de líquido cefalorraquídeo (LCR), neumoencefalocele a tensión, sangrado perioperatorio, accidentes cerebrovasculares y, más raramente, complicaciones infecciosas, osteorradionecrosis. Estas complicaciones pueden ser debidas a errores técnicos, errores de valoración, fallos tecnológicos o a la aparición de un problema insospechado. En el artículo se exponen las posibles complicaciones y su solución. Se hace especial hincapié en la reconstrucción de la base de cráneo y se describe el colgajo nasoseptal de Hadad-Bassagasteguy como un avance muy significativo en la resolución de las fístulas de LCR postoperatorias (AU)

Major complications associated with endoscopic approaches are the same as those associated with traditional skull base approaches. The most frequent are cerebrospinal fluid leaks, tension pneumocephalus, bleeding, cerebrovascular accidents and, more rarely, infectious complications and osteoradionecrosis. These complications may be caused by technical errors, deficient assessment, technical failure or unexpected problems. The present article describes the possible complications and their solutions. Special emphasis is placed on skull base reconstruction and the Hadad-Bassagasteguy naso-septal flap as a major advance in the resolution of postoperative cerebrospinal fluid leaks (AU)

Time sparing and effective procedure for dural closure in the posterior fossa using a vicryl mesh (Ethisorb®) / Cierre de duramadre en cirugía de fosa posterior con una malla de vicryl (Ethisorb®): un procedimiento simple y efectivo

Introduction. Dural defects and cerebrospinal fluid (CSF) leaks are a common problem following posterior fossa surgery. The management includes either nonoperative management (e.g. external lumbar drainage) or surgical re-exploration. Objectives. We present our surgical, clinical and histopathological experience of dural closure in the posterior fossa. In order to avoid CSF leaks we developed a simple but effective and time-sparing method using a well-cut sheet of a vicryl-poly-pdioxanone mesh (Ethisorb®) covering the whole defect of the craniectomy. Additional fibrin glue or sealant is not necessary. Special attention was focused upon the frequency of postoperative complications, in particular infection rate and CSF leaks. Patients. 85 patients were treated with vicryl mesh as dural substitute after posterior fossa surgery due to distinct pathologies. An illustrative case is presented. Results. In none of the patients a postoperative infection was observed. Four patients presented postoperative CSF leakage and were treated by percutaneous lumbar drainage. Three of the patients improved completely, requiring no additional treatment. Only in one case defect covered by a vicryl mesh, a surgical reexploration became necessary. Conclusion. We consider the vicryl mesh (Ethisorb®) as an ideal dural substitute especially for the dural closure of the posterior fossa (AU)

Introducción. Los defectos en el cierre de duramadre y por consiguiente fístulas de líquido cefalorraquídeo son comunes en cirugía de fosa posterior. El tratamiento incluye manejo conservador o no quirúrgico como drenaje lumbar externo de líquido cefalorraquídeo, cuando éstas medidas fallan se requiere de una nueva cirugía. Objetivos. Con el propósito de evitar fístulas de líquido cefalorraquídeo en cirugía de fosa posterior desarrollamos un método simple, pero efectivo, que permite ahorrar tiempo quirúrgico utilizando una malla de viyril-poly-p-dioxanone (Ethisorb®) para cubrir por completo el defecto de la craniectomía. No se requiere del uso adicional de adhesivo de fibrina. Nuestra experiencia clínica, quirúrgica y hallazgos histopatológicos con ésta técnica de cierre dural se discuten en el presente artículo así como las complicaciones, en particular infección y presencia de fístulas de líquido cefalorraquídeo. Pacientes. En 85 pacientes sometidos a cirugía de fosa posterior debida a diferentes patologías, se utilizó una malla de vicryl (Ethisorb®) como sustituto de duramadre. Se presenta un caso que ilustra nuestra técnica. Resultados. En ninguno de los casos se presentó infección postoperatoria. Cuatro casos presentaron fístula de líquido cefalorraquídeo y fueron tratados con drenaje lumbar externo; tres pacientes mejoraron por completo sin requerir otras medidas. Sólo en un caso se requirió de exploración quirúrgica. Conclusiones. De acuerdo con los resultados y complicaciones, consideramos que la malla de vicryl (Ethisorb®) es un sustituto de duramadre ideal, en particular para cirugías de fosa posterior (AU)

Preoperative serum fibrinogen level predicts postoperative pulmonary complications after lung cancer resection.

BACKGROUND: Patients undergoing pulmonary resection are thought to be at high risk for the development of postoperative pulmonary complications (PPCs), and these complications may lead to serious morbidity. The purpose of this study was to identify the factors associated with postoperative pulmonary complications in patients undergoing lung cancer resection and to determine the effect of PPCs on survival. METHODS: The study involved a retrospective review of 635 patients who had undergone curative resection for lung cancer. The patient group included 504 males (79.4%), and the overall mean age was 61.3 years. Patients were classified as those who had experienced PPCs (PPCs group, n = 105, 16.5%) or those who had not (no-PPCs group, n = 530, 83.5%). RESULTS: The surgical procedures performed were 101 pneumonectomies (15.9%), 505 lobectomies (79.5%), and 29 lesser resections (4.6%). Cancer types comprised 330 squamous cell carcinomas (52.0%), 255 adenocarcinomas (40.2%) and 50 others (7.8%). Univariate analysis showed that the following factors were predictors for PPCs: male sex, erythrocyte sedimentation rate, preoperative serum fibrinogen level, pulmonary function, chronic obstructive pulmonary disease, smoking, double primary cancer, and surgical duration. Multivariate logistic regression showed that preoperative serum fibrinogen level (p < 0.001), surgical duration (p < 0.0001) and being male (p = 0.02) were significant predictors of PPCs. Overall survival 3 years after surgery was 68.2% in no-PPCs group and 38.8% in PPCs group (p < 0.0001). Regardless of tumor staging, overall survival differed significantly between PPCs and no-PPCs groups, whereas disease-free survival did not. CONCLUSIONS: Higher preoperative serum fibrinogen levels, longer surgical duration, and being male were the predictive factors for PPCs in surgical candidates. The development of PPCs was linked to a shortened overall survival.

[Predictive biochemical indicators of a postlaryngectomy pharyngocutaneous fistula: a clinical study]. / Indicadores bioquímicos predictivos de fístula faringocutánea postlaringuectomía: un estudio clínico.

UNLABELLED: The aim of this clinical study was to determinate biochemical predictor indicators of postlaryngectomy pharyngocutaneous fistula. PATIENTS AND METHODS: We have studied 100 patients with T2- 4 a laryngeal and piryform sinus carcinoma who underwent a laryngectomy. All patients were ASA 2-3. We studied serum albumin, protein serum level, cholesterol and lymphocites in each patient. These variables underwent statistical analysis (p < 0.05). RESULTS: 19% of the patients developed a postlaryngectomy pharyngocutaneous fistula, with a long-stay of 25 days vs. 10 days of stay in patients without postlaryngectomy pharyngocutaneous fistula. 7 postlaryngectomy pharyngocutaneous fistula needed surgical repair. Low serum albumin (< 3.5 g/dL) and a low level of serum proteins (< 6.5 g/dL) were predictive indicators of postlaryngectomy pharyngocutaneous fistula (p < 0.05). CONCLUSIONS: Our results suggest that a low-level of serum proteins and albumin are predictive clinical parameters of postlaryngeal pharyngocutaneous fistula.

Indicadores bioquímicos predictivos de fístula faringocutánea postlaringuectomía: un estudio clínico / Predictive biochemical indicators of a postlaryngectomy pharyngocutaneous fistula: a clinical study

Introducción: El objetivo de este trabajo será identificar posibles indicadores bioquímicos predictores de la aparición de fístula faringocutánea tras laringuectomía y revisar el tratamiento quirúrgico de este problema. Material y métodos: Se seleccionaron 100 pacientes con carcinoma epidermoide T2-4 de laringe y seno piriforme clasificados como ASA 2-4 tratados mediante cirugía. Las variables estudiadas fueron la albúmina plasmática, las proteínas totales, el colesterol sérico y el número total de linfocitos. Se realizó estudio estadístico mediante Chi-cuadrado. Resultados: El 19% de los pacientes laringuectomizados presentaron fístula faringocutánea en el postoperatorio, con una estancia media hospitalaria de 25 días frente a 10 días en postoperatorio sin fístula postlaringuectomía. Fue necesario tratamiento quirúrgico del faringostoma en 7 de los 19 pacientes, que se realizó a los 25 días de la laringuectomía de media. Se identificó como marcadores bioquímcos predictivos de faringostoma proteínas totales <6,5 g/dL y albúmina plasmática <3,5g/dL (p < 0,05). El 45% de los enfermos presentaban un colesterol sérico <180. Conclusiones: Nuestros resultados sugieren qué identificación prequirúrgica hipoproteinemia e hipoalbuminemia se asocian a alto riesgo de aparición de fístula faringocutánea tras laringuectomía (AU)

The aim of this clinical study was to determinate biochemical predictor indicators of postlaryngectomy pharyngocutaneous fistula. Patients and methods: We have studied 100 patients with T2- 4 a laryngeal and piryform sinus carcinoma who underwent a laryngectomy. All patients were ASA 2-3. We studied serum albumin, protein serum level, cholesterol and lymphocites in each patient. These variables underwent statistical analysis (p < 0.05). Results: 19% of the patients developed a postlaryngectomy pharyngocutaneous fistula, with a long-stay of 25 days vs. 10 days of stay in patients without postlaryngectomy pharyngocutaneous fistula. 7 postlaryngectomy pharyngocutaneous fistula needed surgical repair. Low serum albumin (< 3.5 g/dL) and a low level of serum proteins (< 6.5 g/dL) were predictive indicators of postlaryngectomy pharyngocutaneous fistula (p < 0.05). Conclusions: Our results suggest that a low-level of serum proteins and albumin are predictive clinical parameters of postlaryngeal pharyngocutaneous fistula

High serum tumor necrosis factor-alpha levels are associated with lack of response to infliximab in fistulizing Crohn's disease.

OBJECTIVES: Infliximab, a chimeric monoclonal antibody directed against tumor necrosis factor-alpha (anti-TNF-alpha), has been effective in the treatment of patients with active Crohn's disease and with fistulas. We investigated the effect of infliximab on circulating cytokines and acute phase proteins in patients with fistulas to determine the clinical response to anti-TNF-alpha. METHODS: A total of 36 patients with fistulizing Crohn's disease were selected for study. Serum from patients was drawn before the infusion on day 0 and at wk 2, 4, 6, 8, and 10 after completion of treatment. Circulating concentrations of TNF-alpha, interleukin-1beta (IL-1beta), and IL-6 were measured by ELISA. The functional activity of circulating TNF-alpha was assessed by the WEHI 164 TNF-alpha bioassay. Acute phase proteins were also determined. RESULTS: Elevated TNF-alpha, IL-1beta, IL-6, and acute phase proteins were observed in patients with Crohn's disease. Of the patients with fistulas, 22 (61.1%) responded to treatment. Before receiving infliximab, higher levels of serum TNF-alpha were found in patients who did not respond to infliximab compared with those who did (median interquartile range 26, 0-245 pg/ml; n = 14 vs 0, 0-22 pg/ml, n = 22). Patients showed no change in circulating levels of TNF-alpha during the course of the study. CONCLUSIONS: This treatment produces a clinical improvement in about two-thirds of CD patients with fistulas. The circulating levels of TNF-alpha are associated with the response to infliximab and could help to identify patients who would benefit from anti-TNF-alpha treatment.

A case of bronchopleural fistula detected by monitoring plasma endothelin-1.

Levels of endothelin (ET)-1 peptide are transiently increased after major physical stress. While studying sequential changes in plasma ET-1 levels during various types of stress, we noticed that the level of plasma ET-1 began to rise 10 days post-operatively in one patient with lung cancer who had undergone a left lower lobectomy. 35 days postoperatively a bronchopleural fistula became clinically manifest. The case is presented and the use of plasma ET-1 as an indicator is discussed.

Protein profile of human perilymph: in search of markers for the diagnosis of perilymph fistula and other inner ear disease.

Recent developments in high-resolution two-dimensional polyacrylamide gel electrophoresis, combined with amino acid sequencing and computer-assisted image analysis, have allowed separation of approximately 100 proteins and identification and quantitation of some 30 proteins in human perilymph. The majority of proteins were found to be present in perilymph at levels in basic agreement with the total protein gradient between perilymph and plasma (1:35). However, several striking differences were observed: (1) beta 2-transferrin, known to be absent from normal plasma but present in cerebrospinal fluid, was detected in perilymph at a concentration roughly equal to that in cerebrospinal fluid; and (2) two high-density lipoprotein-associated apolipoproteins--apo D (formerly PLS:33) and apo J or NA1 and NA2 (formerly PSL:29/30), the latter showing identity with SP40/40, or cytolysis inhibitor--were found to be present at concentrations 1 to 2 orders of magnitude higher when examined in terms of total protein and to be comparable with or higher than plasma levels when examined in terms of absolute concentrations. The functional significance of the extremely high levels of the two apolipoproteins is not known at this time. An attempt was made to use beta 2-transferrin, as well as apo D and apo J (NA1/NA2), as markers for the diagnosis of perilymph fistula, one of the most controversial and challenging problems for the otologist today. It was determined that the technique is indeed applicable when relatively pure fistula samples are analyzed. Limitations and potential improvements of the technique are discussed. In addition, the potential usefulness of two-dimensional polyacrylamide gel electrophoresis in other pathologic conditions of the inner ear is discussed briefly.

Serum transferrin as a prognostic indicator of spontaneous closure and mortality in gastrointestinal cutaneous fistulas.

OBJECTIVE: This study determined whether there are any laboratory or other features that will enable prediction of spontaneous closure in patients with gastrointestinal cutaneous fistulas. SUMMARY BACKGROUND DATA: Although the anatomic criteria for spontaneous closure of gastrointestinal cutaneous fistulas have been presented by several authors, less than 50% of such fistulas tend to close, even in the most recent series. METHODS: A group of patients with gastrointestinal cutaneous fistulas with anatomical features favorable to study were investigated with respect to a series of parameters including the usual demographic parameters, plus fistula output, number of blood transfusions, presence of sepsis, as well as metabolic parameters including serum transferrin, retinol-binding protein, thyroxin-binding prealbumin, and serum albumin. RESULTS: Of 79 patients with 116 fistulas, 16 (20.3%) died. Causes of death were uncontrolled sepsis in eight patients and cancer in five patients. Postoperative fistulas constituted 80% of the group. The presence of local sepsis, systemic sepsis, remote sepsis (such as pneumonia or line sepsis), the number of fistulas, fistula output, and the number of blood transfusions were not predictive of spontaneous closure, whereas serum transferrin was predictive of spontaneous closure. Serum transferrin, retinol-binding protein, and thyroxin-binding prealbumin were predictive of mortality. CONCLUSIONS: Serum transferrin does not appear to be an entirely independent variable, but seems to identify those patients with significant remote sepsis, systemic sepsis, and neoplasia in whom these processes are clinically significant. The results, if confirmed, and provided that nutritional needs are met, suggest that short-turnover proteins, particularly serum transferrin, might be useful in predicting which patients with gastrointestinal cutaneous fistulas should undergo surgery despite anatomic criteria favorable for spontaneous closure.

Management of malignant air leak in a child with a neonatal high-frequency oscillatory ventilator.

A 10-year-old, 36-kg child with a malignant air leak who failed conventional mechanical ventilation and high-frequency jet ventilation was successfully treated with a neonatal high-frequency oscillatory ventilator for 31 days. Since the air leak resolved with minimal hemodynamic compromise, this technique may have application in the management of respiratory failure and air leak in the older and larger child for prolonged periods of time.

Parenteral and enteral nutrition and the enterocutaneous fistula treatment. I. Investigations on fistula output, nutritional status complications.

Prospective evaluation were made of 45 patients with postoperative small bowel fistulas treated with total parenteral nutrition (TPN) and enteral nutrition (EN) between 1971-1988. The administration of TPN in the early treatment of enteric fistulas decreased the mean fistula output significantly (p < 0.05-0.001) and provided an effective tool in the control of high-output fistulas. The electrolyte contents of different fistula secretions were unchanged and the losses through the fistulas depended on the daily output. In patients with high-output fistulas acid-base balance disturbances had to be corrected. When comparing two parenteral nutrition regimens (carbohydrate+amino acids /CH + AA/ versus carbohydrate + amino acids + fat /CH + AA + F/) both facilitated the reduction of fistula secretion (in high-output fistulas. CH + AA = -50.2%; CH + AA + F = -49%). Positive nitrogen balance was achieved in non septic patients after 13 days of treatment. Improvement of serum protein and albumin occurred by the time of fistula healing. In non surviving patients significant decrease in protein synthesis was observed. Out 7 of 75 central venous catheters yielded positive bacterial cultures (9.3%). In 5 patients autopsy proved generalized sepsis. The use of parenteral and enteral nutrition proved to be a powerful method for controlling the enterocutaneous fistulas and maintaining the nutritional integrity of patients.

The management of chyle fistula.

Over a recent 4-year period, 823 neck dissections that included the lower jugular lymph nodes were performed. Of the 823, 14 (1.9%) patients developed chyle fistulas. Two other patients developed fistulas, one after undergoing a gastric transposition, and the other after a scalene node biopsy. All 16 patients were initially managed conservatively with closed-wound drainage and low-fat nutritional support; this was successful in only 4 patients, 3 of whom had peak 24-hour chyle drainage of less than 600 cc. The remaining 10 patients required open-wound management, which included operative ligation in 4 instances. Continued conservative treatment with an open neck wound resulted in significant additional hospitalization. Our experience indicates that closed-wound management of a chyle fistula is likely to fail when peak 24-hour fistula output exceeds 600 cc. Considering the cost and morbidity of conservative treatment, early reoperation may be appropriate in those patients with high fistula output.

Evaluation of the effects of lymph drainage by a thoracic duct fistula in experimental peritonitis.

Previous studies suggest that systemic endotoxemia in peritonitis is mainly related to lymphatic transport via the thoracic duct. Rats with fecal peritonitis but with or without a lymph draining thoracic duct fistula were studied with reference to the concentrations of endogenously produced endotoxin in arterial plasma, hemodynamic parameters, organ blood flow, blood corpuscle parameters, glucose and lactate metabolism and survival. Lymph drainage significantly reduced the endotoxin concentrations in arterial plasma, but did not totally prevent systemic endotoxemia, and was related to maintained total peripheral vascular resistance. On the other hand, peritonitic rats without lymph drainage, and consequently higher endotoxin concentrations, had a significant fall in vascular resistance combined with a compensatory rise in cardiac output. Lymph drainage also contributed to a smaller decrease of platelet and leucocyte counts while no effect was observed on glucose metabolism. Despite the effect of lymph drainage on hemodynamic and hematologic responses no effect on survival time was recorded.

Ultra-high-frequency jet ventilation in a bronchopleural fistula model.

High-frequency ventilation techniques have been demonstrated to be useful in decreasing gas loss from bronchopleural fistulas. We performed the present study to evaluate the impact of a new jet ventilator design and ventilatory frequency on hemodynamics, gas exchange, and bronchialstump gas flow in an animal model of bronchopleural fistula. Ten pigs underwent a right-sided thoracotomy and right-sided upper pulmonary lobectomy with cannulation of the upper lobe bronchus for measurement of bronchial fistula flow rate. Animals underwent a random sequence of conventional ventilation (12 to 20 breaths per minute), conventional high-frequency jet ventilation (120 breaths per minute), and ultra-high-frequency jet ventilation (UHFJV; 450 breaths per minute). Hemodynamic measurements were similar in the three ventilatory modes, but oxygenation was best with UHFJV. Bronchial fistula flow was lowest with UHFJV and greatest with conventional ventilation. Ultra-high-frequency jet ventilation demonstrated superior oxygen loading, adequate carbon dioxide elimination, and the least flow through the fistula, suggesting that both ventilator design and frequency are important therapeutic variables in the management of major airway disruption.