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1.
Eur J Cardiothorac Surg ; 17(6): 702-9, 2000 Jun.
Article in English | MEDLINE | ID: mdl-10856863

ABSTRACT

OBJECTIVE: Esophageal resection with diversion and staged reconstruction of the upper gastrointestinal (GI) tract is an option in the management of complex problems. This study characterizes circumstances, indications, outcomes and their predictors for staged reconstruction, and estimates the optimal timing for reconstruction. METHODS: Between October 1981 and March 1999, 43 patients were identified with planned staged reconstruction. Twenty-six had esophageal cancer, and 17 had complications of benign disease. Primary diversion with esophageal resection was needed in 16 patients, and secondary diversion with takedown of previous esophageal reconstruction was needed in 27. Common indications were failed esophageal anastomosis and esophageal perforation. Death before and death after reconstruction were considered as competing risks. Multivariable analyses were used to estimate the optimal timing of reconstruction. RESULTS: The survival was 75, 21 and 9% at 3 months, 5 and 10 years, with survival only somewhat better (P=0. 06) among patients having benign versus malignant disease. A similar proportion of patients died before reconstruction as underwent reconstruction, resulting in only 17 reconstructions, typically 9 months after diversion. The risk factors for death included cancer and primary diversion. The survival was best for benign disease when reconstruction was early. The survival was poor after reconstruction in the few patients with malignant disease. CONCLUSIONS: Patients requiring staged esophageal reconstruction are heterogeneous, with malignant or benign disease, and primary or secondary diversion. The outcome is poor, and is influenced by the pathology and timing of diversion. Patients with benign disease should be reconstructed as early as feasible; reconstruction is rarely indicated for patients with cancer.


Subject(s)
Esophageal Diseases/pathology , Esophageal Diseases/surgery , Esophagectomy/methods , Plastic Surgery Procedures/methods , Adult , Aged , Aged, 80 and over , Anastomosis, Surgical/methods , Esophageal Diseases/mortality , Esophagostomy/methods , Female , Humans , Male , Middle Aged , Multivariate Analysis , Postoperative Complications , Predictive Value of Tests , Plastic Surgery Procedures/mortality , Registries , Reoperation , Retrospective Studies , Risk Assessment , Survival Rate , Treatment Outcome
2.
Circulation ; 94(9 Suppl): II376-80, 1996 Nov 01.
Article in English | MEDLINE | ID: mdl-8901778

ABSTRACT

BACKGROUND: It has been reported that A1 adenosine receptor antagonists are highly effective for the prevention and early treatment of ischemia-reperfusion injury of isolated perfused cat lung, which suggests that activation of A1 adenosine receptors is important in ischemia-reperfusion injury of the lung. In addition, preconditioning ischemia reduces ischemia-reperfusion injury of the lung and heart. Moreover, activation of A1 adenosine receptors by adenosine and selective A1 adenosine receptor agonists mimics the protective effects of preconditioning ischemia in the heart. It has been reported that prior treatment with selective A1 adenosine receptor agonists results in a rapid uncoupling of A1 adenosine receptors from signal transduction mechanisms. In the heart, these effects of A1 adenosine receptor agonists have not been reported. However, if prior treatment of ischemia of the heart with adenosine or A1 adenosine receptor agonists results in uncoupling of A1 adenosine receptors from signal transduction mechanisms that produce injury after prolonged ischemia and reperfusion, A1 adenosine receptor antagonists should provide a protective effect similar to these treatments for ischemia-reperfusion injury of the heart. Therefore, it was the purpose of these experiments to investigate the effect of selective A1 adenosine receptor antagonists on ischemia-reperfusion injury of the heart. METHODS AND RESULTS: With the use of a regional infarct model in open-chest cats, the left anterior descending artery or first diagonal branch was occluded for 1 hour followed by 2 hours of reperfusion. Infarct size (area of necrosis/area at risk; AN/AR) was estimated with the use of nitroblue tetrazolium staining. The selective A1 adenosine receptor antagonists xanthine amine congener (XAC; 0.1 mg.kg-1.h-1), bamifylline (BAM; 10 mg.kg-1.h-1), 1,3-dipropyl-8-cyclopentylxanthine (DPCPX; 10 micrograms.kg-1.min-1) administered as continous intravenous infusions for 1 hour before ischemia [DPCPX (I)], or DPCPX 30 micrograms.kg-1.min-1 administered intravenously during 30 minutes of ischemia and 30 minutes of reperfusion [DPCPX (I/R)] significantly (P < .05) reduced AN/AR from 52.2 +/- 3.8% (control, n = 5) to 23.4 +/- 6.6% (XAC, n = 5), 34.9 +/- 3.6% (BAM, n = 5), 15.9 +/- 2.9% [DPCPX(I), n = 5], or 13 +/- 3.2% [DPCPX (I/R), n = 5]. CONCLUSIONS: A1 adenosine receptor antagonists significantly reduce ischemia-reperfusion injury of the heart. A1 adenosine receptor antagonists may be useful for the prevention or early treatment of ischemia-reperfusion injury of the heart after coronary artery bypass graft surgery or cardiac transplant surgery and during or after angioplasty or thrombolytic therapy of the heart.


Subject(s)
Myocardial Ischemia/physiopathology , Myocardial Reperfusion Injury/prevention & control , Purinergic P1 Receptor Antagonists , Animals , Arrhythmias, Cardiac/etiology , Cats , Hemodynamics/drug effects , Myocardial Infarction/pathology , Xanthines/pharmacology
3.
Ann Thorac Surg ; 62(3): 662-9, 1996 Sep.
Article in English | MEDLINE | ID: mdl-8783990

ABSTRACT

BACKGROUND: Triiodothyronine (T3) administration after cardiopulmonary bypass has been shown to significantly improve cardiac performance. The present study was undertaken to elucidate the effects of T3, when administered as an intravenous bolus, on both cardiac energetics and stroke work-oxygen utilization (EW/LVVO2) efficiency. METHODS: In both unstressed and stressed hearts, energetics were evaluated at baseline and 2 hours after intervention in an in vivo sheep preparation. In the first group (n = 5) sheep received saline vehicle. In the second group (n = 9) sheep received an intravenous bolus of 1.2 micrograms/kg of T3. In the third group (n = 7) sheep received a 2-hour intravenous infusion of dobutamine at a rate of 5 micrograms/kg/min. RESULTS: In the unstressed heart, T3 improved cardiac function at no cost in oxygen consumption by decreasing afterload and hence improved EW/LVVO2 efficiency. In contrast, dobutamine improved unstressed cardiac function by increasing contractility at the cost of increased oxygen consumption and thus decreased EW/LVVO2 efficiency. Triiodothyronine optimized ventriculoarterial coupling for efficiency, but dobutamine optimized coupling for maximal work. In the stressed heart, T3 again improved EW/LVVO2 efficiency, but dobutamine had the opposite effect. CONCLUSIONS: The bolus administration of T3 improves unstressed cardiac performance through optimization of ventriculoarterial coupling for EW/LVVO2 efficiency, primarily through vasodilation. Triiodothyronine also increases efficiency in the stressed heart. This study supports the use of T3 in cardiac operations to improve cardiac performance with no cost in oxygen consumption characteristic of inotropic agents.


Subject(s)
Arteries/physiology , Triiodothyronine/pharmacology , Ventricular Function, Left/drug effects , Animals , Arteries/drug effects , Cardiotonic Agents/pharmacology , Coronary Circulation/drug effects , Dobutamine/pharmacology , Elasticity , Hemodynamics/drug effects , Myocardial Contraction/drug effects , Myocardium/metabolism , Oxygen Consumption/drug effects , Sheep , Stroke Volume/drug effects , Vascular Resistance/drug effects
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