Transurethral thermotherapy in the management of benign prostatic hyperplasia

To elucidate the intradialytic urea concentration gradients, we examined 26 hemodialysis patients wearing a double-lumen central venous catheter during their first or second fistula-punctured dialysis session. In 17 patients (group A), after 60 and 240 minutes of treatment with a mean blood flow of 196.4 +/- 9.9 mL/min, blood urea nitrogen (BUN) was measured in blood samples taken simultaneously from the central venous catheter, a vein in the arm opposite the access site, and the arterial and venous lines of the dialyzer. In 16 patients (group B), after 60 minutes of treatment with a mean blood flow rate of 197.5 +/- 12.3 mL/min, BUN was measured in blood samples taken from the dialyzer arterial line and then, after decreasing the blood flow to 50 to 60 mL/min for 1 minute, in samples taken from a vein in the arm opposite the access site, the central venous catheter, and the dialyzer arterial line. In group A, the mean BUN values in the dialyzer arterial line at 60 and 240 minutes were found to be 3.7% +/- 3.7% and 3.5% +/- 3.4% higher than the corresponding values in the central veins, respectively (P = NS between 60 and 240 minutes). In group B, after 1 minute of low blood flow, this difference was 1.5% +/- 2.4% (P = 0.06 compared with group A). The peripheral veins in group A patients at 60 and 240 minutes had 9.7% +/- 5.2% and 10.9% +/- 5.3% higher BUN values, respectively, compared with the central veins. This difference in group B patients after 1 minute of low blood flow was 6.8% +/- 4.2%. Urea access recirculation rate in group A, calculated by the classical three-samples method, was found to be 7.6% +/- 5.0% at 60 minutes and 9.9% +/- 5.8% at 240 minutes (P = NS). In group B, BUN values in the dialyzer arterial line after 1 minute of low blood flow increased significantly by 3.4% +/- 4.5% (P < 0.01). Our study shows that during conventional hemodialysis with a blood flow rate of 200 mL/min, urea concentration in the central veins is lower than in the dialyzer arterial line. This gradient after 1 minute of low-flow dialysis had a tendency to decrease. At the same time, however, the urea concentration gradient between the peripheral and central veins remained high, indicating that during conventional hemodialysis, intercompartmental disequilibrium plays a significant role in the arteriovenous gradient.     

Telomere length, telomerase activity and telomerase RNA expression during mouse mammary tumor progression

The effects of intraportal administration of prostaglandin E1 (PGE1) on portal venous flow, hepatic arterial flow, peripheral tissue blood flow, and systemic arterial flow before and after 60 min total liver ischemia followed by 70% partial hepatectomy in rats were investigated. Total liver ischemia was induced by occluding the hepatoduodenal ligament for 60 min. PGE1 at a dose of 0.5 microg/kg/min was infused intraportally for 15 min before inducing hepatic ischemia (preischemic period) and for 60 min after ischemia (postischemic reperfusion period) in the treatment group. Normal saline was infused in the control group. Seventy percent partial hepatectomy was performed during ischemia. Serum biochemical analysis and liver tissue histology were carried out 1, 3, and 24 h, and 1 and 24 h after reperfusion respectively. One-week survival of the PGE1 group was improved to 70% compared to that of the control group of 30%. Postischemia reperfusion values of portal and peripheral tissue blood flows in the PGE1 group were 6.33 +/- 0.600 ml/min and 27.2 +/- 23.5 (arbitrary), and were significantly different from those of the control group of 4.34 +/- 0.400 ml/min and 23.5 +/- 5.54 (arbitrary), respectively. There was no significant difference in hepatic arterial flow between the two groups. Serum alkaline phosphatase decreased significantly in the prostaglandin group. Histological examination revealed a significant portal venous congestion in the control group 1 and 24 h after reperfusion. The extent of the sinusoidal congestion was also severe in the control group 24 h after reperfusion. It was concluded that PGE1 has a protective effect against liver damage when the liver was injured by warm ischemia and reperfusion followed by partial resection.     

Isolation of fungi belonging to the genera Geotrichum and Trichosporum from human dermal lesions

The purpose of this study was to assess the effect of endotracheal anaesthesia on the activity of lysosomal enzymes in peripheral blood granulocytes. The determinations were carried out before anaesthesia, after 1 hour of anaesthesia and 1 hour after awakening. The activity of lysosomal enzymes was assessed on the basis of the activity of marker-enzymes, i.e. acid phosphatase, acid protease and neutral protease. The lysosomal fraction was prepared by Choduker's method and the activity of lysosomal enzymes was calculated for 100 mug of protein. The obtained results showed a statistically not significant rise in the activity of these enzymes in the lysosomes during anaesthesia without a similar rise in the supernatant. The activity of marker enzymes in lysosomes rose to the initial values after the awakening of patients. Such rapid changes in the activity of lysosomal enzymes seem to depend mainly on the mobilization of the reserve pool of granulocytes from other sources than the peripheral blood and, to a lesser extent, on latency and stabilization of lysosomal membranes by anaesthetic agents used in correctly conducted anaesthesia.     

Diagnostic radiology in the field of traumatology (author''s transl)

Enflurane (Ethrane) was given before operation to 13 neurosurgical patients. 11 of them received halothane for comparison of effects on intracranial pressure (ventricular catheter), blood pressure and central venous pressure during controlled ventilation. Neuroleptanalgesia was used as basic anaesthesia. The results showed that enflurane, when initial pressure levels were between 0-20 mm Hg, had better properties with regard to intracranial pressure than halothane. The intracranial pressure of 6 patients under enflurane rose. Of the remaining patients pressure did not change or even fell. Under halothane, given in a comparable doses, there was always a marked increase of intracranial pressure. If intracranial pressure of one patient under enflurane rose, then the increase by halothane always was more pronounced. The results from 1 patient had to be excluded because of spontaneously occurring plateau waves. Blood pressure was lowered by both agents while central venous pressure remained unchanged.     

Cardiovascular effects of Althesin. Changes in systolic time intervals and peripheral tissue blood flow

Systolic time intervals were studied and peripheral blood flow measurements made in twelve healthy patients before and after intravenous induction of anaesthesia with Althesin 0.05 ml per kg. The changes in systolic time intervals observed were considered to reflect the cardio-depressive properties of the drug. The reduction in peripheral blood flow which occurs in Althesin anaesthesia was confirmed. Measurement of systolic time intervals and peripheral blood flow constitute a simple and sensitive method for the evaluation of the effects of drugs on the cardiovascular system.     

"Stand down for the homeless". Podiatric screening of a homeless population in Cleveland

The reliability of helical CT as sole preoperative diagnostic technique for abdominal aortic aneurysms (AAA) and its accuracy in detecting vascular anomalies in the abdominal region was evaluated retrospectively in 42 patients with asymptomatic AAA > 40 mm. A single breath-holding helical scan was performed with 5 mm slice thickness, during a single injection of contrast medium, resulting in a 20 cm z-axis coverage. Axial images were reconstructed and used to generate high quality multiplanar reformatted images. Digital subtraction angiography (DSA) was performed in the first 18 patients and then in case of associated peripheral vascular disease (6 patients). Helical CT exactly showed, in all cases, the proximal and distal extent of the AAA. The visceral vessels as well as the inferior vena cava and renal veins were always clearly depicted, showing anatomical variants or pathological involvement in 19 patients. DSA gave sufficient details on the distal run-off but did not allow a reliable visualization of the visceral branches, venous anomalies and true extent of AAA. In our experience helical CT should be considered as the sole method for preoperative imaging of AAA. It allows a complete and precise evaluation; it is fast, with low doses of radiations and does not require hospitalization.     

Three-dimensional computed tomographic imaging in the diagnosis of vertebral column trauma: experience based on 21 patients and review of the literature

Postreperfusion syndrome (PRS) is an important cause of hemodynamic deterioration during orthotopic liver transplantation (OLT). We retrospectively studied 94 patients who had undergone OLT in an effort to establish whether the hemodynamic response to clamping of the inferior vena cava (IVC) could be used to predict hemodynamic behavior on reperfusion of the grafted liver. PRS was defined as a decrease in the mean arterial pressure of more than 30% below the baseline value for more than 1 min during the first 5 min after reperfusion of the graft. The patients were divided into two groups: those who developed PRS (PRS group) and those who did not (non-PRS group). We analyzed hemodynamic response before (dissection stage) and after (anhepatic stage) clamping of the IVC. Based on multivariate analysis methods (logistic regression), the percentage of change in the vascular resistance index from before clamping to after clamping of the IVC was an indicator of the risk of developing PRS, with an adjusted odds ratio of 1.04 for each unit of change (ENTER method, P = 0.01). In the non-PRS group, clamping of the IVC was followed by a 47.1% decrease in the cardiac index, compared with a 27.9% decrease in the PRS group (P < 0.05). The systemic vascular resistance index (SVRI) increased by 49% in the PRS group, as opposed to 85.7% in the non-PRS group (P < 0.05). PRS occurred in only 17.5% of patients in whom the SVRI increased by more than 50%. We conclude that the integrity of the vasoconstrictive response (increase in the peripheral vascular resistance greater than 50%) as measured immediately after clamping of the IVC correlates with occurrence of PRS.     

Pre-eclampsia: the effect of intravenous fluid preload on atrial natriuretic peptide secretion during caesarean section under spinal anaesthesia

BACKGROUND: The haemodynamic effect of volume load at elective Caesarean delivery may be modulated by atrial natriuretic peptide (ANP) especially in pre-eclamptic women in whom basal ANP levels are increased. METHODS: We followed the haemodynamic parameters and determined the peripheral venous levels of ANP before and after an intravenous volume preload of 1000 ml of Ringer's acetate solution, followed by a further load of the same volume under spinal anaesthesia in 7 healthy and in 6 pre-eclamptic women. RESULTS: During the preload period the median ANP level increased more (from 14.8 to 22.1 pmol/l, P = 0.03) in pre-eclamptic than in healthy women (from 8.0 to 8.5 pmol/l, NS); while an increment in central venous pressure (CVP) was also greater in pre-eclamptic than in healthy women. The increase in the concentrations of ANP correlated significantly (P < 0.05) with the increase in CVP in the total study group. A significant increase in ANP levels in healthy pregnant women was not seen until during the second infusion period under spinal anaesthesia; in pre-eclamptic women the levels increased further during that period. CONCLUSION: These findings concur with the theory that atrial stretch is a stimulus for ANP release. An exaggerated release of ANP in response to volume loading may aid in the adaptation of maternal circulation to volume load at elective Caesarean delivery in pre-eclamptic women.     

Endocrine stress reaction, hemodynamics and recovery in total intravenous and inhalation anesthesia. Propofol versus isoflurane

This prospective, randomised study compared total intravenous anaesthesia (TIVA) and inhalation anaesthesia with respect to endocrine stress response, haemodynamic reactions, and recovery. METHODS. The investigation included two groups of 20 ASA I-II patients 18-60 years of age scheduled for orthopaedic surgery. For premedication of both groups, 0.1 mg/kg midazolam was injected IM. Patients in the propofol group received TIVA (CPPV, PEEP 5 mbar, air with oxygen FiO2 33%) with propofol (2 mg/kg for induction followed by an infusion of 12-6 mg/kg.h) and fentanyl (0.1 mg before intubation, total dose 0.005 mg/kg before surgery, repetition doses 0.1 mg). For induction of patients in the isoflurane-group, 5 mg/kg thiopentone and 0.1 mg fentanyl was administered. Inhalation anaesthesia was maintained with 1.2-2.4 vol.% isoflurane in nitrous oxide and oxygen at a ratio of 2:1 (CPPV, PEEP 5 mbar). For intubation of both groups, 2 mg vecuronium and 1.5 mg/kg suxamethonium were injected, followed by a total dose of 0.1 mg/kg vecuronium. Blood samples were taken through a central venous line at eight time points from before induction until 60 min after extubation for analysis of adrenaline, noradrenaline (by HPLC/ECD), antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), and cortisol (by RIA). In addition, systolic arterial pressure (SAP) heart rate (HR), arterial oxygen saturation (SpO2), and recovery from anaesthesia were observed. RESULTS. Group mean values are reported; biometric data from both collectives were comparable (Table 1). Plasma levels of adrenaline (52 vs. 79 pg/ml), noradrenaline 146 vs. 217 pg/ml), and cortisol (82 vs. 165 ng/ml) were significantly lower in the propofol group (Table 2, Figs. 1 and 3). Plasma levels of ADH (4.8 vs. 6.1 pg/ml) and ACTH (20 vs. 28 pg/ml) did not differ between the groups (Table 2, Figs 2 and 3). SAP (128 vs. 131 mmHg) was comparable in both groups, HR (68/min vs. 83/min) was significantly lower in the propofol group, and SpO2 (97.1 vs 97.4%) showed no significant difference (Table 3). Recovery from anaesthesia was slightly faster in the propofol group (following of simple orders 1.9 vs. 2.4 min, orientation with respect to person 2.4 vs. 3.4 min, orientation with respect to time and space 2.8 vs. 3.7 min), but differences failed to reach statistical significance. CONCLUSIONS. When compared with isoflurane inhalation anaesthesia, moderation of the endocrine stress response was significantly improved during and after TIVA with propofol and fentanyl. Slightly shorter recovery times did not lead to an increased stress response. With respect to intra- and postoperative stress reduction, significant attenuation of sympatho-adrenergic reaction comparable SAP and reduced HR, sympatholytic and hypodynamic anaesthesia with propofol and fentanyl seems to be advantageous for patients with cardiovascular and metabolic disorders. For this aim, careful induction and application of individual doses is essential.     

Leg blood flow and central circulation at various blood volumes: a peroperative study of nine patients with varicose veins

1. In a group of nine middle-aged patients undergoing varicose vein surgery, cardiac output, right atrial, pulmonary arterial and capillary pressures, and leg blood flow were measured after induction of general anaesthesia but before operation, and also during operation before and after blood substitution. 2. Under anaesthesia, the mean pre-operative blood flows in the superficial and common femoral arteries were 160 ml/min and 280 ml/min respectively. These flows are comparable with those obtained in other studies under similar conditions but lower than values obtained in conscious subjects. During the operation the leg blood flow decreased by 24%. As cardiac output remained unchanged, the fractional leg blood flow fell. After transfusion of 900 ml of blood the leg blood flow doubled. 3. It is concluded that anaesthesia, surgical trauma and variations in blood volume greatly influence the leg blood flow and that an adequate substitution of operative blood loss is of utmost importance to achieve an optimum peripheral circulation.     

Mitochondrial gene mutations and human diseases: a prolegomenon

OBJECTIVE: To compare "central venous pressure" in pediatric patients in a clinical setting as measured from catheters in the infrahepatic inferior vena cava and the right atrium. DESIGN: Prospective, unblinded study. SETTING: Cardiothoracic intensive care unit of a tertiary care university hospital. PATIENTS: Thirty-three pediatric cardiac surgical patients, 2 days to 92 months of age (mean 24 +/- 4 months). INTERVENTIONS: All patients had intraoperative placement of an 8-cm, double-lumen, femoral venous catheter and a transthoracic right atrial catheter. Patients were studied for 0 to 2 days after surgery. MEASUREMENTS AND MAIN RESULTS: Measurements were obtained during mechanical and spontaneous ventilation. Although not statistically identical, measurements of "central" venous pressure in the inferior vena cava and right atrium correlated well (r2 = .87 for mechanical ventilation; r2 = .83 for spontaneous ventilation). Of 31 data pairs in mechanically ventilated patients, the absolute difference in pressures was as large as 3 mm Hg in three patients and <3 mm Hg in all the rest. In 15 spontaneously breathing patients, there were only three data measurements where the difference in pressure was 2 mm Hg and none of the differences was greater. In spontaneously breathing patients, the phasic changes due to respiratory variations in venous pressure were in phase in both the intrathoracic and intra-abdominal catheter positions. CONCLUSIONS: We conclude that while "central" venous pressures measured in the inferior vena cava and in the right atrium are not statistically identical, any differences are well within clinically important limits. Placement of central venous pressure catheters in the inferior vena cava by the femoral venous approach is a reliable alternative to cannulating the superior vena cava in pediatric patients without clinically important intra-abdominal pathology and with anatomic continuity of the inferior vena cava with the right atrium. Relatively short femoral vein catheters allow adequate measurement of central venous pressure without concern for exact catheter tip position and without the risk of right atrial perforation, intracardiac arrhythmias, and inadvertent puncture of carotid and intrathoracic structures. Unlike previously reported results in neonates, we found that the phasic changes of venous pressure with the respiratory cycle were similar in both intrathoracic and intra-abdominal recordings, making this an inappropriate clinical indicator of venous catheter tip position.     

Experimental and clinical study on intraoperative local infusion chemotherapy (ILIC) for advanced gastric carcinoma

An intensive chemotherapy combined with surgery, termed "intraoperative local infusion chemotherapy (ILIC)", was devised. The ILIC procedure is to infuse 50 mg of cisplatin through the feeding artery to the tumor, which has been isolated from blood flow by clamping the stomach and blood vessels, before radical surgery. An experiment in dogs showed considerable free Pt transfer into thoracic lymph after ILIC. Sum total Pt in the thoracic lymph after ILIC (294.5 micrograms/3 h) was 4.3 times that after IV administration (68.3 micrograms/3 h). In ILIC, AUC of free Pt in the thoracic lymph was about 5.8 times that in peripheral blood. ILIC was applied in 24 advanced gastric cancer patients, consisting of 6, 2, 4 and 12 in pTNM stage II, IIIA, IIIB and IV, respectively. Pt concentration of the tissues was high in the tumor (23.22 micrograms/g) and the regional lymph nodes (2.95 micrograms/g) compared to that in the serum (0.45 microgram/ml). The survival rate (Kaplan-Meier) in the ILIC patients was significantly higher than that of control patients (matched pair method) from among patients treated by surgery alone. No fatal complications were encountered in any patient treated by ILIC.     

Transient respiratory augmentation elicited by acute head-down tilt in the anesthetized cat

Acute head-down tilt (AHDT, -30 degrees) in humans induces a transient ventilatory augmentation for 1-2 min accompanied by a high venous return. However, the mechanisms underlying this respiratory response remain obscure because of limitations of experiments carried out in human subjects. The present study was undertaken to determine whether AHDT-induced respiratory augmentation exists in the anesthetized, paralyzed, and ventilated cat and, if so, whether this response depends on 1) the cerebellum, 2) the carotid sinus (CS) and/or vagal afferents, and 3) elevation of central venous return. The integrated phrenic neurogram, arterial blood pressure, central venous pressure (CVP), and end-tidal PCO2 were recorded before, during, and after AHDT. The results showed that AHDT produced a transient ( approximately 2 min) enhancement of minute phrenic activity (approximately 30%) primarily via an increase in peak integrated phrenic neurogram amplitude associated with a remarkable elevation of CVP (approximately 3 min). Cerebellectomy, CS denervation, bilateral vagotomy, or clamping CVP did not affect the presence of the AHDT-induced minute phrenic activity response. These findings demonstrate that the anesthetized cat is a suitable model for investigating the mechanisms involved in AHDT-induced respiratory augmentation. Preliminary studies suggest that this response does not require the cerebellum, CS/vagal afferents, or an associated rise in central venous return.     

ABILHAND: a Rasch-built measure of manual ability

BACKGROUND: Dexamethasone decreases chemotherapy-induced emesis when added to an antiemetic regimen. This study was undertaken to evaluate the efficacy of granisetron-dexamethasone combination for the prevention of postoperative nausea and vomiting (PONV) in female patients undergoing general anaesthesia for breast surgery. METHODS: In a randomized, double-blind manner, 135 ASA I patients, aged 40-65 years, were assigned to receive placebo (saline), granisetron 40 micrograms.kg-1 or granisetron 40 micrograms.kg-1 plus dexamethasone 8 mg i.v. (n = 45 of each) immediately before the induction of anaesthesia. A standard general anaesthetic technique and postoperative analgesia were used. The PONV and safety assessments were performed continuously during the first 3 h (0-3 h) and the next 21 h (3-24 h) after anaesthesia. RESULTS: A complete response, defined as no PONV and no administration of rescue antiemetic medication, during 0-3 h after anaesthesia was 51%, 82% and 96% in patients who had received placebo, granisetron and granisetron-dexamethasone combination, respectively; the corresponding incidence during 3-24 h after anaesthesia was 56%, 84% and 98% (P < 0.05; overall Fisher's exact probability test). No clinically important adverse events were observed in any of the groups. CONCLUSION: Prophylactic use of granisetron-dexamethasone combination is more effective than granisetron alone for the prevention of PONV after breast surgery.     

Nodular melanosis due to epithelial neoplasms: a finding not restricted to regressed melanomas

OBJECTIVE: To measure plasma cortisol responses in calves dehorned using a scoop after administration of local anaesthesia and/or cautery of the wounds. DESIGN: A physiological study with controls. PROCEDURE: There were six treatments: control handling with and without local anaesthesia, dehorning, dehorning after local anaesthesia, dehorning followed by wound cautery, and dehorning after local anaesthesia followed by wound cautery. Blood samples were taken before and after dehorning. RESULTS: Dehorning caused an increase in plasma cortisol concentrations, which decreased a little to plateau values and then declined to pretreatment values 3 to 4 h after dehorning. The peak was smaller after local anaesthesia was administered but when its effects wore off, cortisol concentrations increased and thereafter were similar to those in the dehorned animals. The combination of local anaesthesia and cautery resulted in a plasma cortisol response similar to those in control calves with or without local anaesthesia. CONCLUSIONS: If plasma cortisol concentrations reflect the distress being experienced by the calves, then local anaesthesia reduces the acute distress for about 3 h after dehorning but not during the subsequent 3 to 4 h. Combining local anaesthetic and cautery prevented the significant increase in plasma cortisol following dehorning and may eliminate the acute distress caused by scoop dehorning.     

The effect of Leboyer delivery on blood viscosity and other hemorheologic parameters in term neonates

OBJECTIVE: This study was done to compare postnatal alterations in blood viscosity, hematocrit value, plasma viscosity, red blood cell aggregation, and red blood cell deformability in term neonates undergoing both early umbilical cord clamping and delivery according to the Leboyer method. STUDY DESIGN: The umbilical cords of 15 healthy, term infants were clamped within 10 seconds of birth (early cord clamping), and 15 infants delivered according to the Leboyer method were placed on the mother's abdomen, and the umbilical cords were clamped 3 minutes after birth. Hemorheologic parameters were studied in umbilical cord blood at 2 hours, 24 hours, and 5 days from the time of delivery. RESULTS: The residual fetal placental blood volume decreased from 45 +/- 8 ml/kg (x +/- SD) after early cord clamping to 25 +/- 5 ml/kg after delivery by the Leboyer method. After Leboyer-method delivery, the hematocrit value rose from 48% +/- 5% at birth to 58% +/- 6% 2 hours after delivery, 56% +/- 7% at 24 hours, and 54% +/- 8% after 5 days. Blood viscosity in the Leboyer-method group increased by 32% within the first 2 hours but did not change significantly during the following 5 days. Plasma viscosity, red blood cell aggregation, and red blood cell deformability were not affected by the mode of cord clamping. CONCLUSIONS: Delivery by the Leboyer method leads to a significant increase in blood viscosity as a result of increasing hematocrit value, whereas other hemorheologic parameters are similar to those of infants with early cord clamping.     

Laparoscopically assisted abdominal aortic aneurysm repair: first 20 cases

PURPOSE: Laparoscopic surgery decreases postoperative pain, shortens hospital stay, and returns patients to full functional status more quickly than open surgery for a variety of surgical procedures. This study was undertaken to evaluate laparoscopic techniques for application to abdominal aortic aneurysm (AAA) repair. METHODS: Twenty patients who had AAAs that required a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of transperitoneal laparoscopic dissection of the aneurysm neck and iliac vessels. A standard endoaneurysmorrhaphy was then performed through a minilaparotomy using the port sites for the aortic and iliac clamps. Data included operative times, duration of nasogastric suction, intensive care unit days, and postoperative hospital days. Pulmonary artery catheters and transesophageal echocardiography were used in seven patients. For these patients data included heart rate, pulmonary artery systolic and diastolic pressures, mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index, and end diastolic area. Data were obtained before induction, during and after insufflation, during aortic cross-clamp, and at the end of the procedure. RESULTS: Laparoscopically assisted AAA repair was completed in 18 of 20 patients. Laparoscopic and total operative times were 1.44 +/- 0.44 and 4.1 +/- 0.92 hours, respectively. Duration of nasogastric suction was 1.3 +/- 0.7 days. Intensive care unit stay was 2.2 +/- 0.9 days. The mean length of hospital stay was 5.8 days excluding three patients who underwent other procedures. There were two minor complications, one major complication (colectomy after colon ischemia), and no deaths. For the eight patients who had intraoperative transesophageal echocardiographic monitoring, no changes were noted in heart rate, pulmonary artery systolic pressure, pulmonary capillary wedge pressure, and cardiac index. Pulmonary artery diastolic pressure and central venous pressure were greatest during insufflation without changes in end-diastolic area. Volume status, as reflected by end-diastolic area and pulmonary capillary wedge pressure, did not change. CONCLUSIONS: Laparoscopically assisted AAA repair is technically challenging but feasible. Potential advantages may be early removal of nasogastric suction, shorter intensive care unit and hospital stays, and prompt return to full functional status. The hemodynamic data obtained from the pulmonary artery catheter and transesophageal echocardiogram during pneumoperitoneum suggest that transesophageal echocardiography may be sufficient for evaluation of volume status along with the added benefit of detection of regional wall motion abnormalities and aortic insufficiency. Further refinement in technique and instrumentation will make total laparoscopic AAA repair a reality.     

Colonic ischemia: the Achilles heel of ruptured aortic aneurysm repair

Colonic ischemia is an often fatal complication of abdominal aortic aneurysm (AAA) repair. In elective AAA repair, patency of the inferior mesenteric artery (IMA) has been shown to be an important contributing factor. The purpose of this study was to determine which clinical and operative factors are important in the development of colonic ischemia in ruptured AAA repair. A retrospective review of all patients treated for ruptured AAA over a 7-year period was performed. Of 101 patients who were treated for ruptured AAA, 71 (70 per cent) survived for longer than 24 hours postoperatively, and these patients are the basis for this study. Colonic ischemia, primarily left sided, was a common perioperative complication (n = 24; 35 per cent) requiring colectomy in 11 patients (44 per cent). It carried a 44 per cent mortality compared to 20 per cent in patients without this complication (P = 0.07). Colonic ischemia occurred more frequently in patients with preoperative shock (P = 0.01) and a greater intraoperative blood loss (P = 0.003), but showed no correlation with patient age, co-morbid medical conditions, laboratory values, time to operation, or treatment of the IMA. Most patients with postoperative bowel ischemia were found to have chronic IMA occlusion, including 8 of the 11 patients requiring colectomy. Revascularization would not be feasible in this group. Revascularization of patent IMAs had little effect on outcome. Of the 17 patent IMAs, 9 were reimplanted and 5 (55 per cent) developed bowel ischemia, two of which required colectomy. Eight were ligated and 3 (38 per cent) developed bowel ischemia, one requiring colectomy. The presence of preoperative shock is the most important factor predicting the development of colonic ischemia following ruptured AAA. The incidence of ischemia is not altered by the presence of a patent IMA or with attempts at IMA revascularization. Colonic ischemia remains a significant source of morbidity and mortality in these patients.     

Central haemodynamic and forearm vascular effects of morphine in patients after open heart surgery

Central haemodynamic and forearm vascular changes following administration of morphine i.v. were studied in patients 24--30 h after open heart surgery. Right atrial pressure, heart rate, mean arterial pressure, cardiac output and stroke volume were measured before and after morphine 5 and 10 mg per 70 kg in 14 subjects. In a further group of eight subjects, forearm blood flow was measured after morphine 10 mg per 70 kg. Total systemic and forearm vascular resistance were derived from these measurements. In spite of wide individual variations, significant decreases in mean arterial pressure occurred in most of the patients and appeared to be dose related. Significant decreases in mean cardiac index were noted only after morphine 10 mg per 70 kg. Forearm blood flow increased consistently and significantly and there was a corresponding decrease in vascular resistance. The decrease in mean arterial pressure and the change in forearm vascular resistance indicated that vasodilatation was probably the principle cause of the decrease in arterial pressure, whereas the sustained decrease in cardiac output seemed to indicate an effect on venous capacitance. The predominant action of morphine appears to be peripheral, causing a decrease in vascular resistance and, possibly, an increase in venous capacitance.