Esophageal rupture complicated by a gastrocardiac fistula: review of the literature and report of a successfully treated case.

A 62-year-old man developed a fistula between the right ventricle and the stomach after Thal fundic patching of an emetogenic rupture of the esophagus. He underwent emergency surgical correction of the fistula and survived.

Early management of abdominal trauma: the role of diagnostic peritoneal lavage.

This report reviews the contemporary value of diagnostic peritoneal lavage (DPL) in the assessment of abdominal trauma, and reports the methods and results of its application within one trauma centre (Washington Hospital Center). DPL was reserved for those patients where doubt existed as to the presence of intra-abdominal injury, and gave a very accurate assessment of intraperitoneal injury. The complication rate was 0.4% and the accuracy of DPL was 97.7%. Except for laparotomy, DPL is the most sensitive indicator of haemoperitoneum available. It was first introduced with the aim of reducing the number of missed diagnoses of abdominal injury and it performs this task excellently when a low threshold for positivity is used. The open technique is safest and gives fewer false positive results, and the colorimetric method of analysis of lavage fluid is recommended, with strict adherence to advised criteria for negativity. A clinical algorithm is described, utilizing DPL, aimed at early diagnosis of all intra-abdominal injuries. This was extremely sensitive and failed in only one case in 384 (0.3%). The attendant, non-therapeutic laparotomy rate was 19%, and is regarded as acceptable within the aims of early diagnosis. In this series, there was no mortality or morbidity attached to the use of DPL or from non-therapeutic laparotomy, and there was only one delayed diagnosis in the entire series. No bowel, bladder, diaphragmatic, duodenal or pancreatic injuries were missed or diagnosed late.

The effect of cryosurgery and polymethylmethacrylate in dogs with experimental bone defects comparable to tumor defects.

The effects of liquid nitrogen (LN) and polymethylmethacrylate (PMMA) on normal bone, bone graft incorporation, and reossification were evaluated by simulating a tumor in dogs with experimental bone cavity. Ten skeletally mature mongrel dogs (20 femora) were divided into three groups: Group I, controls; Group II, LN (with and without bone graft); and Group III, PMMA (with and without LN). Roentgenograms, whole-mount histology, and tetracycline fluorescence studies were performed on the distal femur. Correlation of these studies showed that (1) marked trabecular and bone necrosis, extending 7-12 mm around the circumference of the cavity, developed by three and seven weeks after LN but no bony necrosis occurred after PMMA; (2) the pattern of reossification following cryosurgery was delayed and abnormal, demonstrating increased calcification and metaplastic bone formation; (3) cryosurgery decreased the rate of bone graft incorporation; (4) the cryonecrotic rim following cryosurgery correlated with an abortive attempt at peripheral reossification; and (5) cryosurgery had no effect on the articular cartilage. Cryosurgery is effective in causing bone necrosis, whereas PMMA is not, and the pattern of reossification is delayed and altered by freezing. This study suggests that microvascular thrombosis with subsequent ischemic infarction of bone is a major cause of bone necrosis following cryosurgery.

Correlation of coronary arteriograms and left ventriculograms with postmortem studies.

To assess the accuracy of angiographic determinations of disease of coronary arteries and left ventricular myocardium we compared clinical with postmortem coronary arteriograms and left ventriculograms with myocardial pathology in 28 patients, all of whom died postoperatively and within three months of angiography; 19 had ischemic heart disease, four valvular heart disease, and five both. Comparison of pre and postmortem lumenal occlusion in 315 epicardial coronary segments, excluding those operated upon, showed greater than 50% narrowing discrepancies in 21 (7%). Significant coronary artery lesions were overestimated in six and underestimated in 15. Of the six overestimations, three appeared to be due to coronary spasm; of the 15 underestimations, 12 were due to overlapping images; six discrepancies were unexplained. Comparison of wall motion in 140 ventriculogram segments with myocardial pathology, excluding any post-study or perioperative injury, showed good correlation of reduced motion with 48 (34%) infarcted and 10 (7%) aneurysmal segments. However, 58 (41%) other segments had poor or absent ventriculogram motion, with structurally normal myocardium and patent coronary artery supply; 19 were on infarct margins and 39 in dilated or hypertrophied hearts. Thus, premortem coronary arteriographic occlusions generally indicate atherosclerotic narrowing; but decreased or absent segmental wall motion frequently does not indicate a myocardial lesion. It may be attributable to ischemia in the distribution of a critically narrowed coronary artery or it could be due to abnormal ventricular topography.