Excision of the aortic wall in the surgical treatment of acute type-A aortic dissection.

Between March 1986 and September 1988, 38 patients underwent extended aortic resection (aortic valve, ascending aorta, and arch) for acute type-A aortic dissection with aortic valve insufficiency; deep hypothermia and circulatory arrest were used. All patients were operated on within 17 hours of the onset of symptoms. In the first 24 patients, operation was performed by the "inclusion technique." In the last 14 patients, the "excision technique" was used: the ascending aorta and arch was excised, and the aorta was transected at the beginning of the descending thoracic tract. Excision and transection were considered essential to prevent back flow from the false lumen, which is the main source of bleeding, and to allow all anastomoses to be constructed beyond the limits of dissection. The only anastomosis to the dissected aorta was at the distal end of the graft. One of the 14 patients died (7.1%). One patient was reopened for bleeding: blood was issuing from the attachment of the carotid trunks, and the defect was repaired by interposing a bifurcated Dacron graft between the arch graft and the carotid arteries. Extended aortic excision meets the principle of either eliminating as far as possible the diseased aorta or controlling intraoperative and postoperative bleeding. An operation of great magnitude can be considered a life-saving procedure when compared with the high risk of acute type-A aortic dissection.

Extended and total aortic resection in the surgical treatment of acute type A aortic dissection: experience with 54 patients.

Fifty-four patients with acute type A aortic dissection were surgically treated with extended aortic resection. The age of the patients ranged from 22 to 75 years, and all of them were in very critical condition. In 50 patients, the resection extended from the aortic valve (included in 33) to the beginning of the descending thoracic aorta and in 4, from the valve (included in 3) to the aortic bifurcation. Deep hypothermia and circulatory arrest were employed during the aortic arch resection; inclusion of the graft at the end of procedure was done in 44 patients; in the others, the diseased aortic wall was excised. Early mortality was 20 +/- 6% (11/54). Nine deaths were due to persistence of the distal dissection. Acute type A aortic dissection with aortic valve insufficiency should be treated as an emergency with extended aortic resection. As far as control of bleeding and closure of distal dissection are concerned, the best results have been achieved when the diseased aortic wall has been completely excised.

[Emergency gastro-duodeno-cephalo-pancreatectomy for gastroduodenal necrosis caused by ingestion of caustics]. / Gastro-duodeno-cefalo-pancreasectomia d'urgenza per necrosi gastro-duodenale da ingestione di caustici.

Successful treatment of a case of gastroduodenal necrosis caused by the massive ingestion of muriatic acid is described. Total gastrectomy and resection of the duodenum and head of the pancreas were followed by oesophagocolonjejunoplasty. It is suggested that surgery should be as radical and as early as possible in cases where strong acids have been ingested.

[Metabolic preparation for surgical operations and the problem of chronic shock]. / La preparazione metabolica all'intervento chirurgico e il problema dello shock cronico.

Surgical patients with a chronic energy deficit display a particulare metabolic situation known as chronic shock, marked by deficient utilisation of energy. The picture is related to functional disorders of the cell enzymes, following incomplete resynthesis due to the lack of substrates. The main features are: a) lactic metabolic acidosis due to anaerobic oxidation, usually with insufficiency of the Krebs cycle; b) exaggerated protein catabolism, due to utilisation of amino acids as the energy substrate; c) incomplete utilisation of the (mostly endogenous) substrates available, with lactacidaemia, aminoacidaemia, and increased lipidaemia. A rational form of treatment is proposed after careful analysis of these features and their corresponding clinical phenomena.