David B. Skinner

Chronic respiratory symptoms and occult gastroesophageal reflux. A prospective clinical study and results of surgical therapy.

Seventy-seven patients with a primary complaint of persistent cough, wheezing, and/or recurrent pneumonia were evaluated for the presence of occult gastroesophageal reflux disease. Fifty-four patients (70%) had increased esophageal acid exposure on 24-hour pH monitoring of the distal esophagus. In 28% of these patients the respiratory symptoms were thought to be due to aspiration because they occurred during or within 3 minutes after a reflux episode. In the other patients, the respiratory symptoms were either induced by or were unrelated to reflux episodes. The number of respiratory symptoms reported by the patients with increased esophageal acid exposure was directly related to the presence of a nonspecific esophageal motility abnormality (p less than 0.05). This suggested that a motility disorder contributes to aspiration by promoting the aboral flow of refluxed gastric juice. Seventeen patients with increased esophageal acid exposure had an antireflux operation to relieve their respiratory complaints. Patients whose respiratory symptoms induced reflux episodes were not helped by the procedure. Of the other patients, symptoms were abolished by the procedure only in those with normal esophageal motility. It is concluded that the majority of patients suffering from chronic unexplained respiratory symptoms have occult gastroesophageal reflux disease, but only a minority of them are helped by surgery. Carefully performed esophageal function studies are needed to select those patients who will benefit from a surgical antireflux procedure.

Mesenteric vascular disease

Abstract In a patient with acute abdominal pain, the diagnosis of acute mesenteric vascular disease should be suspected immediately if there is a history of previous embolization, atrial fibrillation, or generalized atherosclerosis. Supportive therapy should be instituted promptly and should include treatment for congestive heart failure, hypotension, and dehydration. Heparin should be given intravenously to prevent extension of the occlusion. Angiography is essential in selecting those patients with superior mesenteric artery occlusion who should undergo immediate operation. At surgery, scanning of the revascularized intestine after aortic injection of 99Te-labeled microspheres permits immediate determination of intestinal viability. If angiography demonstrates patency of the superior mesenteric artery, nonocclusive arteriosclerotic disease, venous thrombosis, or inferior mesenteric ischemic colitis is suspected and further supportive therapy and close observation are given. If abdominal findings progress to include peritonitis, laparotomy with intestinal resection is performed in any of these groups. Patients found to have an embolus are carefully evaluated for later corrective cardiac surgery. Patients with extensive atherosclerosis who recover from an acute episode are considered for subsequent elective bypass to avoid future ischemic episodes. This program is clinically practical and offers the hope of greater salvage of patients with decreased operative risk in a disease that has thus far yielded poor clinical results.

Extracorporeal portal decompression using a graphite-benzalkonium-heparin shunt.

TREATMENT of bleeding esophageal varices remains a difficult problem. A significant number of patients with this condition are not suitable for emergency portasystemic venous shunt operations. Recent reports describe the usefulness of dilated umbilical veins in humans as an entry to the portal system for hepatoportography.1 7,8 XWhite,13 Piccone,9 and Christophersen 2 and co-workers used the umbilical vein for portal vein decompression. The accessibility of the umbilical and external jugular veins provides a simple means to construct a temporary extracorporeal portasystemic shunt to control bleeding varices. The dog is a good experimental animal for study of extracorporeal portasystemic shunts since it will not tolerate portal vein ligation.3 6 Canine survival after portal ligation is dependent upon adequate functioning of a shunt. Christophersen et al. concluded from experiments on dogs that anticoagulant agents were necessary to prevent clotting in extracorporeal shunts.2 The undesirability of anticoagulation in patients with bleeding esophageal varices is apparent. Gott and co-workers described a technic for preventing thrombosis on prosthetic materials by bonding heparin to a graphite-benzalkonium surface.4 The purpose of these experiments is to evaluate the effectiveness of extracorporeal portasystemic shunts in dogs without systemic anticoagulation employing tubes coated with grapbite-benzalkonium-heparin (GBH).

Circulation in profound hypothermia

HIBERNATING MAMMALS MAINTAIN effective cardiac action and circulation at temperatures of 5OC for prolonged periods of time [13, 15, 191. Nonhibernatom, on the other hand, undergo cardiac failure and expire at low body temperatures unless rewarmed and resuscitated within a short time [3, 171. Artificial circulation with a pump oxygenator has improved the tolerance of profound hypothermia and dogs have survived long-term with no ill effects after 2 hr at a body temperature below 10% [17]. The effect of maintaining an intact pulsatile circulation in profound induced hypothermia has not previously been reported. A noninvasive pulsatile pumping system, mechanical ventricular assist (MVA) has been extensively studied as a technique for total circulatory support in normothermia [l, 23, 30, 321. The use of the MVA at low body temperatures provides mechanical cardiac function, lack of which is the initial and most obvious cause of circulatory failure. Dogs have been maintained for 2 hr with core temper-