The surgical treatment of stomach ulcers difficult to remove]

Experience in surgical treatment of 154 patients with large gastric ulcers and ulcers of the cardiac part of the stomach is discussed. All the patients underwent resection of the stomach in various modifications with a 2.6% mortality rate. Penetration was encountered in 62.4% of patients with large ulcers and in 69.2% of those with ulcers of the cardia. In 13.6% of patients with "difficult" gastric ulcers ligation of the main trunk of the left gastric artery becomes necessary, which may be the cause of incompetence of the gastrointestinal anastomosis in performance of tubular resection. Intraoperative angiotensiometry showed that in ligation of the trunk of the left gastric artery the intramural blood flow in the distal segment of the tubular gastric stump was reduced by one third. Preservation of the gastroepiploic arteries in mobilization of the stomach in this situation prevents ischemia of the gastric stump. The method of tubular resection makes it possible to avoid subtotal removal of the organ in most patients with gastric ulcers which are hardly removable and allows the Billroth I operation to be carried out.     

Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients treated with renin-angiotensin system inhibitors: effects on systemic and regional hemodynamics

BACKGROUND: Terlipressin has been suggested as the ideal drug to treat anesthesia-induced hypotension in patients under long-term renin-angiotensin system inhibitor treatment for arterial hypertension. The authors compared the effects of terlipressin and norepinephrine on systemic hemodynamic parameters and gastric mucosal perfusion using a laser Doppler flowmetry technique in patients treated with renin-angiotensin system inhibitors who experienced hypotension at induction of anesthesia. METHODS: Thirty-two patients scheduled for carotid endarterectomy under general anesthesia and treated with renin-angiotensin system inhibitors had hypotension after induction of general anesthesia. They were randomized to receive 1 mg of terlipressin (n = 16) or norepinephrine infusion (n = 16) to counteract anesthesia-induced hypotension. A laser Doppler probe was introduced into the gastric lumen. All measurements were performed just before surgery, during hypotension, at 30 min, and at 4 h. RESULTS: Terlipressin produced an increase in mean arterial pressure and a decrease in gastric mucosal perfusion detected by laser Doppler flowmetry (P < 0.05) over 30 min that were sustained for 4 h. During the infusion, norepinephrine produced an increase in mean arterial pressure and in gastric mucosal perfusion detected by laser Doppler flowmetry (P < 0.05). If compared to norepinephrine, terlipressin reduced oxygen delivery and oxygen consumption (P < 0.05) and increased arterial lactate concentrations (P < 0.05). CONCLUSION: This study showed the efficacy of terlipressin in the treatment of hypotension episodes in anesthetized patients chronically treated with renin-angiotensin system inhibitors, angiotensin converting-enzyme inhibitors, and angiotensin II receptor antagonists. However, the negative effects on gastric mucosal perfusion and the risk of iatrogenic oxygen supply dependency of terlipressin need to be taken into account.     

Terlipressin versus Norepinephrine to Counteract Anesthesia-induced Hypotension in Patients Treated with Renin-Angiotensin System Inhibitors: Effects on Systemic and Regional Hemodynamics

Background: Terlipressin has been suggested as the ideal drug to treat anesthesia-induced hypotension in patients under long-term renin-angiotensin system inhibitor treatment for arterial hypertension. The authors compared the effects of terlipressin and norepinephrine on systemic hemodynamic parameters and gastric mucosal perfusion using a laser Doppler flowmetry technique in patients treated with renin-angiotensin system inhibitors who experienced hypotension at induction of anesthesia.

Methods: Thirty-two patients scheduled for carotid endarterectomy under general anesthesia and treated with renin-angiotensin system inhibitors had hypotension after induction of general anesthesia. They were randomized to receive 1 mg of terlipressin (n = 16) or norepinephrine infusion (n = 16) to counteract anesthesia-induced hypotension. A laser Doppler probe was introduced into the gastric lumen. All measurements were performed just before surgery, during hypotension, at 30 min, and at 4 h.

Results: Terlipressin produced an increase in mean arterial pressure and a decrease in gastric mucosal perfusion detected by laser Doppler flowmetry (P < 0.05) over 30 min that were sustained for 4 h. During the infusion, norepinephrine produced an increase in mean arterial pressure and in gastric mucosal perfusion detected by laser Doppler flowmetry (P < 0.05). If compared to norepinephrine, terlipressin reduced oxygen delivery and oxygen consumption (P < 0.05) and increased arterial lactate concentrations (P < 0.05).     

Experimental and clinical study on the lymphatic pathway draining from the distal esophagus and gastric cardia

The intramural and extramural lymphatics draining from the distal esophagus and gastric cardia were studied in 140 mongrel dogs by dye injection technique. A clinical study was also performed on the lymphatic pathway in these regions by radio isotope uptake (RIU). The results were compared with that of lymph node metastases in 113 patients with carcinoma of the distal esophagus and 103 patients with carcinoma of the gastric cardia. The intramural lymphatics between the distal esophagus and gastric cardia were communicated at the central part of the muscularis mucosae. This finding coincided with the results of intramural RIU. The extramural lymphatics from the distal esophagus flowed both upward and downward. Those from the cardia entered the intraabdominal regional lymph nodes, but none was visualized either in the mediastinum or in the thoracic cavity. Similarly, few RIUs were detected in the mediastinal nodes. As the result of partial or total blockade at the cardiac portion of the stomach in dogs, ascending lymphatics reaching the thoracic cavity was observed in 6 of 27 cases. Clinically, the incidence of the mediastinal lymph node metastases were 17.0%. These results indicate that upward lymphatic spreads may occur in cases with cardiac cancer when the descending lymphatic pathway is blocked by the tumor invasion.     

The effects of halothane and epidural anesthesia on the gastric intramural pH and the pH of gastric juice

To evaluate the effects of gastric intramural pH on intraluminal fluid of stomach during halothane anesthesia, the pH of gastric content and the gastric intramural pH measured by noninvasive method under halothane anesthesia were compared with those during epidural anesthesia. Nineteen patients without gastrointestinal disorders who received elective surgery were studied; 14 patients were anesthetized with N2O-O2-halothane and 15 patients were anesthetized with N2O-O2, flunitrazepam and lumber epidural anesthesia. The intramural pH was calculated from the Henderson-Hasselbalch's equation: intramural pH = 6.1 + ([HCO3-]/PCO2 X 0.0307), substituting [HCO3-] in arterial blood for [HCO3-] in tissue and PCO2 in gastric content for PCO2 in tissue. The pH of gastric content was elevated gradually under halothane anesthesia, but it was unchanged under epidural anesthesia. On the other hand the intramural pH was unchanged during both anesthetic methods and there were no significant differences between the two groups. These results suggest that the elevation of the pH of gastric content under halothane anesthesia is not the result of intragastric microcirculatory impairment and halothane may have other suppressive actions on gastric acid secretion.     

Gastric tonometry: effect of sucralfate on calculated intramural pH

Tonometric measurement of gastric intramural pH (pHi) is a noninvasive method to assess adequacy of splanchnic perfusion. Calculation of pHi may be influenced by various factors. This prospective study was designed to determine if stress ulcer prophylaxis with sucralfate interferes with pHi measurement. Twenty-five adult patients admitted to the intensive care unit (ICU) after open heart surgery were studied. Nasogastric tonometers were placed. Patients received sucralfate 1 g via the nasogastric tube 8 hours after termination of surgery, thereafter every 6 hrs. Gastric luminal pH and intramural pH were determined immediately prior and 1 hour after the first sucralfate administration. Gastric intramural pH was calculated from the arterial HCO₃ concentration and the tonometrically determined intraluminal PCO₂ value using the Henderson-Hasselbaich equation. Intraluminal PCO_2(SS) was measured to be 6.86±0.75 kPa prior to sucralfate administration as compared to 6.96±0.68 kPa 1 hour after 1 g sucralfate ( P =0.92). Intramural pH, as calculated by tonometry, was 7.31±0.05 vs 7.31±0.05, and was thus not influenced by sucralfate administration ( P =0.97). Mean gastric intraluminal juice pH was 4.2±1.3 compared to 4.2±1.2 ( P =0.59). These data suggest that sucralfate does not interfere with tonometrically determined intraluminal PCO₂ measurement and calculation of gastric intramural pH.     

Gastric intramural pH in mechanically ventilated patients.

BACKGROUND: The hypothesis that gastric intramural pH (pHi) is predictive of outcome in haemodynamically stable, mechanically ventilated patients was tested in 25 patients on assisted mechanical ventilation for respiratory failure. METHODS: Simultaneous samples of arterial blood and gastric juice were obtained from patients on assist control, synchronised intermittent and pressure control ventilation during the first 48 hours of mechanical ventilation. Gastric pHi was calculated from the equation: pHi= 6.1 + log HCO3/(gastric PCO2 X 0.03). The outcome was survival or death due to respiratory or circulatory failure within 45 days of admission. RESULTS: Gastric pHi proved to be a better predictor of outcome than all presently utilised parameters. Although all patients included in this study were haemodynamically stable and were similar for all laboratory indices, the only variable capable of accurately predicting outcome was gastric pHi. Patients with a normal arterial pH but a gastric intramural pH of less than 7.25 had an observed mortality of 66%. Standard severity of illness scores grossly underestimated mortality rates. The sensitivity and specificity of a gastric pHi value of less than 7.25 in predicting death were 86% and 83%, respectively. A receiver operator curve for all variables exaggerates the superiority of gastric pHi as a predictor of outcome. CONCLUSION: Low gastric pHi, a marker of gastrointestinal ischaemia, may occur in the presence of normal haemodynamics and may be used to predict severity of illness and mortality accurately.     

Effects of short-term fenoldopam infusion on gastric mucosal blood flow in septic shock

BACKGROUND: Inadequate splanchnic perfusion in septic shock is associated with increased morbidity and mortality. As result of splanchnic ischemia, mucosal permeability increases. Considering the implication of improved mucosal perfusion in terms of maintenance of mucosal barrier integrity, dopamine-1 receptor stimulation could be helpful in septic shock. The goal of the current study was to determine the effects of fenoldopam on systemic hemodynamic parameters and gastric mucosal perfusion in patients with septic shock. Furthermore, the authors tested the hypothesis that the addition of fenoldopam (0.1 microg x kg(-1) x min(-1)) to a combination of norepinephrine and dobutamine (5 microg x kg(-1) x min(-1)) may improve gastric mucosal perfusion in septic shock. METHODS: Patients with septic shock were randomized to a double-blind 2-h infusion of fenoldopam (n = 20) or placebo (n = 20). Each group received dobutamine (5 microg x kg(-1) x min(-1)), and the dosage of norepinephrine was adjusted to achieve a mean arterial pressure between 70 and 80 mmHg. A laser-Doppler probe and tonometer were introduced into the gastric lumen. RESULTS: A significant increase in gastric mucosal perfusion, detected by laser-Doppler flowmetry, was observed in the group treated with fenoldopam (P < 0.05). In addition, this increase in microcirculatory flow occurred despite the fact that systemic flow remained unchanged. Differences in gastroarterial partial pressure of carbon dioxide values were not statistically significant in the fenoldopam and placebo groups. CONCLUSIONS: The study showed that, for the same mean arterial pressure, short-term fenoldopam infusion increased gastric mucosal perfusion in patients with septic shock.     

A device for noninvasive assessment of perfusion pressure in the skin of healthy volunteers

A device allowing pressure to be applied to a local skin site where the skin blood flow is followed using laser Doppler flowmetry is described. The blood flow was studied on the back of the hand in eight volunteers before and during brachial arterial occlusion and while the external pressure was increased step by step. The flowmetry value during arterial occlusion was 0.3 +/- 0.1 AU, and when the external pressure was increased to 120 mm Hg the values were similar (p = .44). The skin perfusion pressure, defined as the least external pressure needed to achieve flow cessation, was found to be 92 +/- 16 mm Hg (range 70-111 mm Hg), and the mean arterial pressure was 90 +/- 9 mm Hg (NS). The skin perfusion value is in agreement with that found by others using other techniques for measuring blood flow and a circumferent cuff for applying pressure.     

Methodologies,Devices, and New Surgical Concepts: A Device for Noninvasive Assessment of Perfusion Pressure in the Skin of Healthy Volunteers

A device allowing pressure to be applied to a local skin site where the skin blood flow is followed using laser Doppler flowmetry is described. The blood flow was studied on the buck of the hand in eight volunteers before and during brachial arterial occlusion and while the external pressure was increased step by step. The flowmetry value during arterial occlusion was 0.3 ± 0.1 AU. and when the external pressure was increased to 120 mm Hg the values was similar (p =. 44). The shin perfusion pressure, defined as the least external pressure needed to achieve flow cessation, was found to be 92 ± 16 mm Hg (range 70–111 mm Hg), and the mean arterial pressure was 90 ± 9 mm Hg (NS). The skin perfusion value is in agreement with that found by others using other techniques for measuring blood flow and a circumferent cuff for applying pressure.     

Acidification of arterial blood enhances gastric mucosal injury induced by bile salts in dogs

The influence of intraarterial infusion of hydrochloric acid on gastric mucosal injury induced by topical bile salts was assessed in a canine ex vivo model. Exposure of the gastric mucosa to 5.0 mM sodium taurocholate in acid bathing solution alone resulted in a slight but not significant reduction in intramural pH of gastric mucosa and mild mucosal damage. When hydrochloric acid (0.1 N) was infused directly into the artery perfusing the stomach of the dogs, the intramural pH of gastric mucosa markedly decreased. The mucosal acidification was associated with severe ulcers in all test dogs that received intraarterial infusion of hydrochloric acid. The deleterious effect of intraarterial infusion of hydrochloric acid was not due to ischemia since the gastric blood flow remained relatively unchanged. The severe mucosal ulcerations were perhaps caused by the decrease in the ability of gastric blood to buffer the incoming luminal acid induced by topical bile salts. These results suggest that (1) the pH of arterial blood perfusing the stomach may also be an important determinant in the ability of the gastric mucosa to protect itself against acid injury, and (2) better management of systemic acid-base balance may contribute to a lower incidence of stress ulcers in critically ill patients.     

Three cases of intramural cyst of the esophagus with ciliated epithelium

We had 3 cases of intramural cyst of the esophagus with ciliated epithelium. In Case 1, 13-year-old man, the cyst was lined with ciliated columnar epithelium and had a smooth muscle layer. In Case 2, 37-year-old female, the cyst was lined with ciliated stratified epithelium and had some layers of smooth muscle. In Case 3, 42-year-old male, the cyst was lined with ciliated columnar epithelium and had a smooth muscle layer. In all cases, cartilaginous tissue was not found. They had no complaints and the abnormal shadow was found by chance Chest X-ray film. When the cyst did not have typical diagnostic criteria, clear division into esophageal cyst or bronchogenic cyst is difficult. The bronchus and the esophagus are of the foregut origin, so we suppose the middle type cyst, between esophageal and bronchial, may exist. In Case 2, the cyst was diagnosed as esophageal, because it had some muscle layers. But in Case 1 and Case 3, as the cyst did not have typical diagnostic criteria, we diagnosed them as the inclusion cyst of the esophagus, not as esophageal, not as bronchogenic.     

Noninvasive Positive Pressure Ventilation to Prevent Respiratory Collapse after Extubation: Clinical Case Reports

Respiratory complications often develop in liver transplant recipients, and appropriate respiratory management is crucial to improve patient outcome. To evaluate the clinical usefulness of noninvasive positive pressure ventilation (NPPV) in liver transplant recipients, we established application criteria for NPPV in respiratory management in these patients, as follows: (1) arterial oxygen tension to fraction of inspired oxygen ratio less than 300 and arterial carbon dioxide tension greater than 45 mm Hg; (2) arterial oxygen tension to fraction of inspired oxygen ratio less than 200; (3) respiratory rate greater than 25/min; and (4) presence of severe atelectasis or pulmonary edema. A bilevel positive airway pressure ventilator was used with the pressure level adjusted to minimize patient discomfort. In patients who were not able to tolerate NPPV, it was discontinued. However, it was continued until patients no longer had dyspnea without NPPV or to resolution of the initial indication for NPPV such as hypoxemia, hypercapnia, or atelectasis. Of 36 patients who underwent liver transplantation between 2005 and 2007, NPPV was administered in 6 according to our criteria. After extubation, recipients demonstrated hypoxemia, hypercapnia, tachypnea, severe atelectasis, or pulmonary edema. After treatment, these conditions improved without apparent problems related to treatment with NPPV. In 1 patient, reintubation was required because of deterioration of respiratory function due to systemic infection. In conclusion, NPPV was useful in liver transplant recipients after extubation to prevent respiratory deterioration. For successful NPPV, settings must be individualized for each patient.     

The motor function of a gastric esophagus transplant according to the data of gastroimpedancemetry

The motor function of the artificial esophagus was studied in 50 patients at different terms after resection of the esophagus for cancer. It was found that the lower and middle parts of the transplant had normal gastric peristalsis, the upper part had hyperkinetic peristalsis with spastic contractions. Impaired peristalsis was observed in the esophagus stump in more than half of the patients.     

Hypertension in kidney transplantation

Arterial hypertension in renal transplant patients plays a major role in the progression to chronic allograft failure, and in morbidity and mortality associated with cardiovascular disease. Its cause is diverse, with contributions not only from donor and/or recipient factors, but it also is influenced strongly by the type of immunosuppressive regimen. Despite increased awareness of the adverse effects of hypertension in both graft and patient survival, long-term studies have shown that arterial hypertension in the transplant population has not been controlled adequately. Ambulatory blood pressure measurements provide the advantage of a better assessment of the diurnal blood pressure variation, a predictor of target organ damage and cardiovascular morbidity and mortality events. Although the available data do not support the recommendation of any class of antihypertensive medication as preferred agents for blood pressure management in the transplant population, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers have shown beneficial effects beyond their antihypertensive effects. Clinical data in transplant recipients are emerging that suggest that applying interventions proven to be effective in reducing cardiovascular morbidity and mortality in the general population may be effective for the transplant population.     

Therapeutic modality for esophago-gastric varices analyzed by endoscopic ultrasonography]

For 64 cases with portal hypertensive disease, we investigated the intramural and extramural structure of the stomach and esophagus by endoscopic ultrasonography (EUS). Variously developed intra- or extra-mural vascular structures had a relationship to the endoscopic variceal form, and the communicating (inflow) vessels to varices were found in 35 of 50 primary treated cases (70%). We classified the esophago-gastric varices into three types according to the vascular structure, such as the esophageal type, the esophago-gastric type and the solitary gastric type. From the analyses of these collateral structures, we should select a treatment as follows. In the esophageal type which has a few inflow vessels, it is easy to eliminate the varices by obturating the inflow vessels by endoscopic injection sclerotherapy (EIS). In the esophago-gastric type, which has many enlarged inflow vessels, the Hassab operation is effective to devascularize extramural inflow vessels, and the combination of EIS is necessary to sclerous the intramural varices. In the solitary gastric type which is a part of the downward porto-systemic shunt, Hassab operation is recommended to prevent the rupture of varices for the subtype with intramural running vessels, but conservative therapy is enough for the subtype without intramural running vessel.     

A review of microvascular measurements in wound healing

The microcirculatory evaluation in patients affected by arteriopathic or venous ulcers is usually carried out using laser Doppler flowmetry, transcutaneous oxygen (transcutaneous pressure of oxygen, TcPO(2)), and carbon dioxide (transcutaneous pressure of carbon dioxide, TcPCO(2)) measurements and capillaroscopy. These techniques provide significant pathophysiologic and prognostic information. TcPO(2) and TcPCO(2) diagnose and classify the extent of arterial disease in the leg ulcers caused by arterial disease; the prognostic value is recognized, though doubts about its prognostic potential exist in the case of leg ulcer. Laser Doppler flowmetry is able to identify the first functional impairment in the early stages of the arterial disease and in the complicated venous insufficiency. Capillaroscopy gives us morphological and quantitative parameters of the capillary bed that is damaged in arteriopathic and venous ulcers; nevertheless, it does not provide us with definite prognostic indexes. Combining the 3 methods may contribute to yield objective measures in the clinical management of lower extremity ulcers.     

A new laser Doppler interface for the continuous measurement of the rat gastric mucosal blood flow

The laser Doppler system (LD) has been proposed for a tissue blood flowmetry. However, its accuracy is dependent on the pressure and direction of the laser probe. Therefore, we have devised a new interface for the measurement of the gastric mucosal blood flow in rats keeping the probe constant in pressure and direction. This interface is a small cylinder with one end fixed upon the gastric serosa and the other end fixed externally upon the skin. The laser probe adjusts exactly in direction and pressure inside this button. The LD apparatus processes two shifted beams with a differential amplification and a root mean square. It delivers an index (LDI) from 0 to 10. This interface was tested in 3 groups of rats, comparing the mucosal (open stomach) with the serosal gastric LDI and the same serosal LDI with a 133Xe washout flow. Finally, the interface was used in control and restrained rats. The gastric serosal LDI was found to be similar to the mucosal LDI. The correlation between the LDI and the 133Xe washout flow was good, with a coefficient of 0.9. Finally, the LDI of the gastric mucosal blood was significantly different in control and stressed rats. This new interface makes the LD more reliable for the monitoring of gastric mucosal flowmetry. It has the same accuracy as the xenon washout and additionally it is simpler, cheaper and may be repeated or even be used continuously.     

Lymph node metastasis from early gastric cancer: endoscopic resection of tumour.

The clinicopathological features of 748 solitary early gastric cancers were examined with regard to lymph node metastasis. Among several factors, only depth of invasion and tumour size correlated significantly with node involvement. Tumours which satisfy the following criteria may not metastasize to lymph nodes: (1) confined to the mucosa; (2) less than 1.5 cm in diameter; (3) macroscopically elevated; (4) macroscopically depressed, without intramural ulcers or ulcer scars (endoscopically, no fold convergence); and (5) histologically differentiated. With a recently developed endoscopic technique small gastric tumours can safely be resected. The cut margin and depth of tumour invasion can be verified histologically in the specimen. If an endoscopically removed tumour satisfies the above criteria, further surgical intervention may be optional as the outcome of endoscopic resection is comparable to that of radical surgery in the absence of node involvement.     

Selection of the treatment for esophagogastric varices

Summary In 57 cases with portal hypertensive disease, we investigated the intramural and extramural structure of the stomach and the esophagus by endoscopic ultrasonography (EUS). Variously developed intra- and extramural vascular structures had a relationship to the endoscopic variceal form, and communicating (inflow) vessels to varices were found in 28 of the 43 primary cases treated (65%). We then classified the esophagogastric varices into three types according to the vascular structure, such as the esophageal type, esophagogastric type, and solitary gastric type. Based on the analysis of these collateral structures, we selected the treatment as follows. In the esophageal type, which has a few inflow vessels, it is easy to eliminate the varices by obturating the inflow vessels by endoscopic injection sclerotherapy (EIS). In the esophagogastric type, which has many enlarged inflow vessels, the Hassab operation is effective in devascularizing the extramural inflow vessels, and the combination of EIS is necessary to sclerose the intramural varices. In the solitary gastric type, which is a part of the downward portosystemic shunt, the Hassab operation is recommended to prevent rupture of the varices for the subtype with intramural running vessels, but conservative therapy is enough for the subtype without.