Seatbelt injury to the abdominal aorta.

Seatbelt injury to the abdominal aorta is a rare finding with an unresolved mechanism. We present a case in which a rear-seat passenger wearing a lap belt was involved in a motor vehicle accident. Injuries sustained included a contused abdominal aorta. At the time of aortic repair, the involved segment was found to be atheromatous, had an intimal tear, and a flap that caused complete occlusion. Graft replacement was carried out employing a 12-mm DeBakey woven dacron prosthesis, which restored satisfactory circulation to both lower limbs. The patient developed myoglobinemia and subsequently died due to multiple organ failure 19 days following the accident. Tearing against the vertebral column, and bowel loop entrapment, in high-speed deceleration have been implicated as injury mechanisms as well as impingement by the belt or metal buckle, in such injuries. Also, our patient had existing atheromatous plaque, which was ruptured.

Reflux patterns in patients with achalasia without operation.

Five patients with achalasia who had not had an operation underwent esophageal manometry and 24-hour, ambulatory pH monitoring to determine the pattern and extent of esophageal reflux. One patient had reflux within normal limits. In 2 patients, reflux occurred 0.5% of the total time and no episodes of supine reflux were recorded. In the 2 remaining patients, reflux was measured 16.8% and 55.3% of the total time; however, in both patients, these results were influenced by lengthy bouts of supine reflux. These indices of reflux were not influenced by differences in resting lower esophageal sphincter tone, position, or length. Twenty-four-hour esophageal pH monitoring can be useful in the preoperative assessment of patients with achalasia, and the information obtained might influence the choice of operative procedure.

Reflux patterns following limited myotomy without fundoplication for achalasia.

Five patients with achalasia underwent limited myotomy without fundoplication. Surgery reduced mean lower esophageal sphincter resting pressure significantly (p less than .05) from 31 +/- 9.7 mm Hg to 16.1 +/- 8.2 mm Hg. Twenty-four-hour ambulatory esophageal pH studies demonstrated that the percentage of time the pH in the distal esophagus was below 4 was similar whether the patient was upright or supine (6.6 +/- 6.5% of total time upright vs. 9.1 +/- 12.7% of total time). Reflux events that occur in the supine position may be significant because of their prolonged duration resulting from the absence of normal secondary peristalsis in the body of the esophagus. Patients with achalasia who have undergone esophagomyotomy without fundoplication do not appear to experience more reflux than control subjects with normal esophageal function.