Outcome after transthoracic resection of carcinoma of the oesophagus and oesophago-gastric junction.

AIMS: To assess the postoperative morbidity and mortality, length of stay and long-term survival after resection of carcinoma of the oesophagus and gastro-oesophageal junction, after establishment of a new surgical team unit between thoracic and gastroenterologic surgeons. METHODS: We analysed the prospective collected data of 166 consecutive patients who underwent a transthoracic oesophageal resection between June 1997 and December 2003. RESULTS: There were 119 men and 47 women. The median age was 63 years (range 36-81). Fifty-five patients (33%) had squamous cell carcinoma and 111 (67%) had adenocarcinoma. Postoperative complications occurred in a total of 60 patients (36%). Ten patients (6%) died postoperatively, eight (4.8%) due to medical and two (1.2 %) due to surgical complications. The median postoperative length of stay was 11 days (range 6-75). The overall 3- and 5- years survival was 35.6% and 30.6% respectively. Survival was adversely affected by patient age and tumor stage. CONCLUSIONS: Concentrating resection for carcinoma of the oesophagus and oesophagogastric junction to a dedicated team of specialists, including both gastrointestinal and thoracic surgeons as well as thoracic-anaesthesiological know-how, results in acceptable complication rates as well as low mortality rates especially due to surgical complications.

[Continuous measurements of cardiac output in the perioperative period]. / Kontinuerlig måling af hjertets minutvolumen i den perioperative periode.

Management of critically ill patients is based on knowledge of fundamental physiological variables. Automatized and continuous measurement of these variables is preferable. A new system based upon the thermodilution method has been developed to measure cardiac output automatically and continuously. We evaluated the system in the potentially unstable perioperative period with possible great and rapid changes in cardiac output. Twenty patients, scheduled for open heart or abdominal aortic aneurysm surgery, were included into the study, which was approved by the local ethical committee. The patients were monitored for up to 30 hours. At random intervals five iced bolus thermodilution cardiac output (BCO) determinations were made and compared to the continuous measurements (CCO). Two hundred and thirty-one pairs of data were obtained. The cardiac outputs ranged from 2.5-14.9 l/min. The absolute bias was 0.31 l/min (95% limits of agreement -1.4 l/min to 2.0 l/min). The mean relative error was 4.7% with a standard deviation of the relative error of 15.4%. The linear regression was represented by: CCO = 11.352 x BCO - 0.36. The correlation coefficient R was 0.90 (p < 0.001). In conclusion, the CCO measurement technique is a promising clinical method. The method is straightforward, requires no calibration, is independent of vascular geometry and measures with its limitations volumetric flow. Finally automatic and continuous patient monitoring provides more information and has potential to reveal previously undetected haemodynamic events.

Continuous cardiac output measurements in the perioperative period.

Management of critically ill patients is based on knowledge of fundamental physiologic variables. Automatized and continuous measurement of these variables is preferable. A new system based upon the thermodilution method has been developed to measure cardiac output automatically and continuously. We evaluated the system in the potentially unstable perioperative period with possible great and rapid changes in cardiac output. Twenty patients, scheduled for open heart or abdominal aortic aneurysm surgery, were included in the study, which was approved by the local ethical committee. The patients were monitored up to 30 hours. At random intervals five, iced, bolus thermodilution cardiac output (BCO) determinations were made and compared to the continuous cardiac output measurements (CCO). Two hundred and thirty-one pairs of data were obtained. The cardiac outputs ranged from 2.5-14.9 l.min-1. The absolute bias was 0.31 l.min-1 (95% limits of agreement -14 l.min-1 to 2.0 l.min-1). The mean relative error was 4.7% with a standard deviation of the relative error of 15.4%. The linear regression was represented by: CCO = 1,1352.BCO-0.36. The correlation coefficient R was 0.90 (P < 0.001). In conclusion, the CCO measurement technique is a promising clinical method. The method is straightforward, requires no calibration, is independent of vascular geometry and measures with its limitations volumetric flow. Finally automatic and continuous patient monitoring provides more information and has potential to reveal previously undetected haemodynamic events.

[Complications and late sequelae after nasotracheal intubation]. / Komplikationer og senfølger efter nasotrakeal intubation.

A total of 379 patients admitted to the Intensive Care Unit (ICU) for mechanical ventilation were prospectively investigated for lesions of the nose, nasal cavity, ears and larynx during and after nasotracheal intubation. One to two years later, the surviving patients were questioned to investigate late persisting sequelae. During intubation and up to five days following extubation, inflammatory changes and ulceration of the nostrils or nasal septum were found in respectively 76 (20%) and 110 (29%) patients. There were bleedings from the nasal cavity in 67 (19%) and fractures of the conchae in 40 patients (11%). Hoarseness was noted in 135 patients (42%). Inflammatory changes and ulcerations of the nostril and nasal septum were correlated to the duration of intubation. Among the 281 patients included in the follow-up study, 100 (35%) had symptoms from the nose and nasal cavity. Sixty-five (24%) had symptoms related to the ears, 56 (20%) to the maxillary sinus, 81 (29%) to the voice and 90 (32%) to the throat. Increasing duration of intubation was found to be correlated to persisting symptoms from the larynx. Former ulcerations of the nose were associated with a tendency toward nasal bleeding. To avoid as many complications as possible from the nose and nasal cavity, we recommend orotracheal intubation. As late sequelae from the larynx increase with the duration of intubation, perhaps tracheostomy should be performed earlier than is general practice today, but that has to be proven in forthcoming studies.

Complications and late sequelae following nasotracheal intubation.

A total of 379 patients admitted to the ICU for mechanical ventilation were prospectively investigated for lesions on the nose, nasal cavity, ears and larynx during and after nasotracheal intubation. One to two years later, the surviving patients were questioned to investigate late persisting sequelae. During intubation and up to 5 days following extubation, inflammatory changes and ulceration of the nostrils or nasal septum were found in 76 (20%) and 110 patients (29%), respectively. There were bleedings from the nasal cavity in 67 (19%) and fractures of the conchae in 40 patients (11%). Hoarseness was noted in 135 patients (42%). Inflammatory changes and ulcerations of the nostril and nasal septum were correlated to the duration of intubation. Among the 281 patients included in the follow-up study, 100 (35%) had symptoms from the nose and nasal cavity. Sixty-five (24%) had symptoms related to the ears, 56 (20%) to the maxillary sinus, 81 (29%) to the voice and 90 (32%) to the throat. Increasing duration of intubation was found to be correlated to persisting symptoms from the larynx. Former ulcerations of the nose were associated with a tendency to nasal bleeding. To avoid as many complications as possible from the nose and nasal cavity, we recommend orotracheal intubation. As late sequelae from the larynx increase with the duration of intubation, perhaps tracheostomy should be performed earlier than is general practice today, but that has to be proven in forthcoming studies.

Computer-aided analysis of gastrointestinal pressure recordings. Comparison with manual scoring.

The aim of the present study was to compare computer-based and visual/manual scoring of pressure recordings from the gastric antrum and duodenum. The computer system was based on three separate principles of recognition: moving average, tracking base line, and threshold filters. Computer scoring resulted in the detection of more contractions than visual/manual scoring, owing to inclusion of artefacts of duration and amplitude above the selected thresholds. Owing to its unreliability, visual/manual scoring led to inclusion of some contractions of below-borderline amplitude or duration. The median difference in the frequency of contractions was, however, 0 min-1. There was close agreement on amplitudes of contractions. As the differences between visual/manual analysis and computer-aided scoring by the present system are of an unimportant magnitude and as computer-based scoring is consistent, we conclude that computer-aided analysis is preferable to visual/manual analysis.

The effect of nasotracheal intubation on the paranasal sinuses. A prospective study of 434 intensive care patients.

A total of 434 patients admitted to the intensive care unit for mechanical ventilation were followed prospectively to investigate the influence of a nasotracheal tube on the paranasal sinuses. Twenty-five patients died before the examination was completed. The rest were examined for clinical symptoms of sinusitis. If sinusitis was suspected or the patients were intubated for 5 days or more, an x-ray of the sinuses was performed. In patients intubated for less than 5 days (N = 357), sinusitis was clinically suspected in three, but radiographically verified in only one. In patients intubated for 5 days or more (N = 47), 23 (49%) had affection of the paranasal sinuses. Patients needing a nasotracheal tube should be examined for sinusitis if they are intubated for more than 5 days or if unexplained fever, sepsis or purulent nasal secretion develops. If the suspicion is confirmed, the nasotracheal tube should be removed.

Is minitracheotomy a simple and safe procedure? A prospective investigation in the intensive care unit.

Patients with imminent respiratory failure due to sputum retention were assessed for minitracheotomy (MT). MT was considered potentially useful in 79 patients but only attempted in 73, 54 men and 19 women, aged 23-81 years (median 65 years). Insertion of the cannula failed in 4 cases. Sputum retention and atelectasis were successfully treated in 87% (N = 60). Treatment by MT in medical and neurological patients seems as effective as in surgical patients (success rate 81% versus 90%). The frequency of complications was 16%. Most complications were insignificant and occurred during cannulation, but a few severe complications were seen. To minimize the number of these it is essential that MT is done only by doctors who are familiar with the procedure. MT can be recommended for treatment of sputum retention and atelectasis in surgical and medical/neurological intensive care patients with preserved cough function.

Changes of blood pressure and cerebral arterio-venous oxygen content differences (AVDO2) with and without bupivacaine scalp infiltration during craniotomy.

In 20 patients subjected to craniotomy for supratentorial cerebral tumours, the effect of scalp infiltration with bupivacaine before incision was evaluated by measuring mean arterial blood pressure (MABP) and cerebral arterio-venous oxygen content differences (AVDO2) repeatedly during the operation. All patients were given halothane 0.5% anaesthesia. Ten patients were given bupivacaine 0.25% and ten patients were given normal saline for scalp infiltration prior to incision. The study was performed in a double-blind randomized fashion. Significantly higher values of MABP (P less than 0.0005) after incision were found in the saline group compared to the bupivacaine group. Significantly lower values of AVDO2 (P less than 0.0005) after incision were seen in the saline group compared to the bupivacaine group. The results indicate that the increase in MABP associated with a decrease in AVDO2, suggesting an increase in CBF and cerebral hyperperfusion, is reduced by using bupivacaine scalp infiltration prior to incision.

[Sinusitis caused by nasotracheal intubation]. / Sinuitis som følge af nasotrakeal intubation.

Sinusitis following nasotracheal intubation (NTI) is an almost overlooked complication. The pathogenesis is believed to be development of oedema of the nasal mucosa due to irritation by the tube in the nasal cavity. The size of the tube is probably not important, whereas the duration of intubation is of major importance. The infection is often caused by Gram-negative microorganisms. The frequency is found to be 0.3% in short term intubation (less than 5 days) and 40.4% in long term intubation (greater than 5 days). In neurosurgical patients treated with NTI sinusitis is found in 52% and 100% of the patients. In adults the indications for prolonged NTI instead of orotracheal intubation and early tracheostomy should be considered carefully. If fever or sepsis develops in patients treated with NTI, investigations for sinusitis should be included in the search for focus. When sinusitis has developed, the tube should be removed, and the patient tracheostomised. If this treatment fails, surgical drainage should be performed.

Ossification of the cricothyroid membrane following minitracheotomy.

We describe a case in which a repeat minitracheotomy (MT) could not be performed 2 months after the first. The cricothyroid membrane seemed calcified and histological examination showed scar formation with dystrophic calcification and heterotopic bone formation. Scar formation following MT may have caused these alterations making repeat access to the airway through the membrane impossible.

Per- and postoperative changes in the arterio-venous oxygen content difference (AVDO2) in patients subjected to craniotomy for cerebral tumours.

Sixteen patients with supratentorial cerebral tumours were subjected to craniotomy under thiopentone, fentanyl, nitrous oxide, halothane anaesthesia during moderate hypocapnia (PaCO2 level 4.0 kPa). The arterio-venous oxygen content difference (AVDO2) was measured peroperatively, and repeatedly during the first three hours after extubation. Peroperatively the level of AVDO2 averaged 8.0 vol% during opening of the dura, and decreased to 7.0 vol% during closure of the dura (P less than 0.05). Immediately after extubation the AVDO2 decreased to 4.3 vol% (P less than 0.05), and during the next 3 hours a gradual increase to 5.8 vol% (P less than 0.05) was disclosed. In individual cases the postoperative changes in AVDO2 correlated fairly well with changes in mean arterial blood pressure (MABP), but other factors including duration of the operation, age of the patients, size of the tumour, level of PaCO2 and adaptation to prolonged hyperventilation during operation are supposed to be responsible for the low levels of AVDO2 observed in the postoperative period.

Minitracheotomy in the treatment of postoperative sputum retention and atelectasis.

Minitracheotomy (MT) is a new method for the treatment of sputum retention and atelectasis. Through a 1-cm incision in the cricothyroid membrane (coniotomy), a specially designed tube is placed in the trachea, allowing suction to be performed. Fifteen patients, aged 37-78 years (median 62 years), with postoperative sputum retention, atelectasis and imminent respiratory failure, were treated with suction by MT. Thirteen of the patients recovered from their respiratory problems, while two patients had to be treated with intermittent positive pressure ventilation (IPPV). During insertion, one case of external bleeding and one case of subcutaneous and mediastinal emphysema were seen, while no complications were seen during cannulation. The duration of cannulation was 4-38 days (median 10 days). Following decannulation the incisions were airtight within 1 day and healed within 3 days. Ten patients left hospital in good health and five died because of surgical complications and/or cardiovascular failure. MT seems to be effective in the treatment of sputum retention and atelectasis. Advantages over other invasive methods make it a method of first choice. The method involves few complications and is often so effective that avoidance of intubation and IPPV is possible.

Epidural blockade in the treatment of preterm labour.

A case of premature labour induced by necrosis in a fibromyoma followed by laparotomy is described. Unsuccessful treatment with ritodrine was followed by successful treatment with epidural analgesia. The possible role of a sympathetic blockade is discussed.