[Radiotherapy of lymphatic fistula and lymphocele]. / Strahlentherapie von Lymphfisteln und Lymphozelen.

BACKGROUND: The treatment of persistent postoperative lymphatic fistulas or lymphoceles is often a problem. Approximately 2% of patients will develop lymphatic fistula after vascular surgery. This can require a long lasting conservative therapy. If spontaneous cure fails, a second operation with wound revision becomes necessary. We studied low-dose percutaneous radiotherapy to be used as an alternative treatment in addition to conservative or surgical therapy. PATIENTS AND METHODS: Between 1989 and 1998 29 patients (25 with lymphatic fistulas, 4 with lymphoceles) received radiation therapy. Depending on the depth of the fistula 27 patients were treated with electrons (7 to 18 MeV). Two other patients suffering of retroperitoneal lymphoceles received a treatment with photons (15 MV). In all patients the fractionation was 4- to 5 x 1.0 Gy/week and the dose ranged from 3 to 12 Gy depending upon the onset of the radiation therapy effect. RESULTS: In 27 of 28 evaluable patients a complete disappearance of the fistula or lymphocele was achieved by radiation during therapy or shortly afterwards. In 1 case no benefit was observed after a dose of 11 Gy. This patient required further surgery with wound exploration. CONCLUSION: Low dose percutaneous radiotherapy (up to 10 to 12 Gy) is effective to heal lymphatic fistulas and lymphoceles without complications. Individual dosage is required because doses even lower than 10 Gy may be effective. Radiation can be effective even after a failed conservative therapy or instead of surgery.

Increased tissue endothelin-1-like immunoreactivity in the internal mammary artery of patients with diabetes or hypercholesterolemia modulates the graft flow in the peri-operative period.

OBJECTIVE: Peri-operative ischemic episodes following coronary artery bypass grafting with the internal mammary artery (IMA) are thought to be due to a vasospasm of this conduit. Endothelin-1 (ET-1) is a potent vasoconstrictor by itself and increases the response to other vasoconstrictor stimuli. This study focused on the possible role of an enhanced tissue ET-1-like immunoreactivity in the perioperative reaction of the IMA in patients with diabetes or hypercholesterolemia. METHODS: Specimens of the distal part of the IMA from 46 patients (mean age 58.5 years, four women, 42 men) were studied prospectively. Nine of those patients were diabetic and 26 had evidence of hypercholesterolemia. Another cohort of 20 IMA specimens was stained retrospectively; 10 of those biopsies were from patients that had experienced transient ischemic events peri-operatively in the myocardial area supplied by the IMA. The biopsies were examined histologically and immunohistochemically (rabbit polyclonal ET-1 antiserum, three-step avidin-biotin complex) with regard to their immunoreactivity to tissue ET-1. RESULTS: An immunoreactivity to ET-1 (graded 0-3) was present in 89% of the biopsies. The reactivity was significantly higher in patients with hypercholesterolemia ( 1.92+/-0.74) when compared to controls (1.0+/-0.63) (P = 0.04). The reactivity was also increased in patients with non-insulin-dependent diabetes mellitus (2.1+/-0.79), when compared to controls (P = 0.02). Mostly transient ischemic events in the area supplied by the IMA seemed to occur more frequently when the biopsies revealed a higher immunoreactivity to ET-1. They showed an increased reactivity to ET-1 (2.27+/-0.76) compared to 10 patients with an uneventful peri-operative course (1.66+/-0.71 ) (P = 0.04). CONCLUSIONS: This study provides evidence that the internal mammary artery is not a passive conduit. Vasospasm or vasoconstriction, in particular at its distal end, may occur more frequently in patients with hypercholesterolemia or diabetes, and may lead to post-operative ischemic events.

Hypertonic saline dextran resuscitation during the initial phase of acute endotoxemia: effect on regional blood flow.

BACKGROUND AND METHODS: Small-volume resuscitation by means of bolus application of hypertonic saline solutions has been demonstrated to restore central hemodynamics and regional blood flow in severe hemorrhagic and traumatic shock. The aim of this study was to elucidate the potential of this new concept for treatment of profound hypovolemia and microcirculatory deterioration associated with sepsis and endotoxic shock. In a porcine model of acute hyperdynamic endotoxemia (elicited by continuous iv infusion of Salmonella abortus equi endotoxin for 3.5 hrs), small-volume resuscitation applying hypertonic-hyperoncotic solutions was analyzed for its effect on central hemodynamics, oxygen delivery (Do2), and regional blood flow. Fluid therapy was initiated when the pulmonary artery occlusion pressure (PAOP) tended to decrease (at 43 to 52 mins of endotoxemia), and consisted of 4 mL/kg bolus infusion of either 7.2% sodium chloride, 10% dextran, or 10% dextran in 7.2% sodium chloride; thereafter, PAOP was maintained by controlled infusion of 6% dextran-60. In a control group, 6% dextran-60 was given without preinjection of hypertonic-hyperoncotic solutions. RESULTS: On small-volume resuscitation, cardiac index significantly increased within 5 mins in all groups, while mean arterial pressure remained unchanged. Fluid requirements were significantly reduced after small-volume resuscitation and the hyperdynamic circulatory state was maintained until the end of the observation period; Do2 as well as blood flow to heart, kidneys, and splanchnic organs remained high. CONCLUSION: Small-volume resuscitation by means of hypertonic saline-dextran proved the most effective, and seems to be an attractive supportive therapy to prevent microcirculatory failure in sepsis and endotoxemia.