[Fatal cervical edema following diagnostic fine needle aspiration].
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Biopsy, Needle↗
Biomedical subjects
J Sand
Publications and source records attributed to J Sand.
Surgical complications after total thyroidectomy and resections for differentiated thyroid carcinoma.
Differentiated thyroid carcinoma often has a favourable prognosis. However, there is no unanimity about the surgical procedure used. In this analysis we evaluated the surgical complications of 178 patients operated on for differentiated thyroid carcinoma during a 12-year period. 110 of the patients were operated in one session and 68 in two. Total thyroidectomy was performed in 106 patients and ipsilateral lobectomy together with contralateral subtotal resection in 72 patients. Tumour was bilateral or multicentric in 59 patients (33%). Hypoparathyroidism occurred in eight patients (4%), without differences between total thyroidectomies and lobectomy plus subtotal resections. Hypoparathyroidism tended to be more common after completion resection than after completion thyroidectomy (4/28 vs 1/40; P = 0.08). Accidental injury to the recurrent laryngeal nerve occurred in one patient (0.6%) during a contralateral resection. During a median follow-up of 4.5 years, tumour recurrence was detected in 22 patients (12%). In papillary carcinoma it was more common in patients who had underwent lobectomy plus contralateral resection than after total thyroidectomy (11/60 vs 3/88; P < 0.01). However, the median follow-up times were unequal. In conclusion, total thyroidectomy and even completion thyroidectomy is as safe as less radical lobectomy together with contralateral resection. Thus, total thyroidectomy should be offered to all patients with differentiated thyroid carcinoma until there is a reliable method to recommend for those patients who can be treated with less radical procedures.
Adenocarcinoma, Follicular↗
Peptidergic innervation of human sphincter of Oddi.
The innervation of the sphincter of Oddi (SO) has been extensively studied experimentally, but human studies have not been published, which is why this study was undertaken. Biopsies, taken by gastroscopy-biopsy forceps from duodenal epithelium of the papilla of Vater and from ampullary epithelium after sphincterotomy, did not demonstrate nerves and could not be used for studying SO innervation. Therefore SO specimens were obtained from brain-dead organ donors (N = 5) and from autopsies (N = 14). By staining with a myelin marker S-100, a rich network of nerves was demonstrated in SO. The occurrence of vasoactive intestinal polypeptide (VIP), peptide histidine-isoleucine (PHI) (or its immunologically similar human equivalent peptide histidine methioninamide, PHM), neuropeptide Y, calcitonin gene-related peptide (CGRP), galanin, substance P, enkephalin, bombesin, and somatostatin were studied by immunohistochemical technique. SO demonstrated immunoreactivity for VIP, PHI (PHM), neuropeptide Y, CGRP, galanin, somatostatin, substance P, and enkephalin, but no immunoreactivity was observed for bombesin. The SO immunoreactivity was similar in specimens from organ donors and from autopsies of victims of violence without pancreatobiliary diseases (N = 3) when the specimens were taken within 48 hr of death. Autopsy specimens of SO from subjects with gallstone disease (N = 5), recurrent pancreatitis (N = 3) or periampullary carcinoma (N = 3) also demonstrated similar immunoreactivity. We conclude that VIP-, PHI- (PHM-), neuropeptide Y-, CGRP-, galanin-, substance P-, somatostatin-, and enkephalin-like immunoreactivity occur in human SO. These neuropeptides may have role in the neural control of human SO function.
Adult↗
Primary hyperparathyroidism: surgical results of 147 consecutive patients.
Surgery has been used to treat primary hyperparathyroidism since 1925. The indications for surgery in mild hypercalcaemia and in asymptomatic patients are not clearly established, but the attitude to surgery is liberal if the surgical results are good. The value of preoperative localisation studies prior to the initial neck exploration is also questionable. We evaluated the results of 147 consecutive patients, who had been operated on for hyperparathyroidism. We analysed also the results of preoperative localisation studies. Most of the patients had symptoms which could be related to primary hyperparathyroidism. Hypercalcaemia was cured by surgery in 96% of the patients, but six patients needed more than one procedure. Permanent hypocalcaemia ensued in 3% of the patients. Complications were rare, but occurred more often in patients with previous thyroid or parathyroid operations, and in patients who needed a simultaneous thyroid operation. Preoperative ultrasonography, which was made in 135 patients, revealed an abnormal parathyroid gland correctly in 47% of the patients. The result was incorrect in 26%, and there was no finding in 27% of the patients. Thallium-technetium subtraction scintigraphy, which was made in 96 patients, was correct in 29%, incorrect 41%, and uninformative in 30% of the patients. Angiography was performed in eight patients with a correct finding in six patients. We conclude that operative treatment for primary hyperparathyroidism is successful and safe in experienced hands. The reliability of noninvasive localisation studies is poor, and they are not necessary before the initial neck explorations.
Adult↗
Neuropeptides in pig sphincter of Oddi, bile duct, gallbladder, and duodenum.
To better understand the complex structure and function of the sphincter of Oddi (SO), the occurrence and localization of nine neuropeptides, including vasoactive intestinal polypeptide (VIP), bombesin, neuropeptide Y, peptide histidine-isoleucine (PHI), calcitonin gene-related peptide (CGRP), galanin, substance P, serotonin, and somatostatin, were studied by immunohistochemical methods in the pig SO. The SO innervation was compared to gallbladder, common bile duct, and duodenal innervation. Specimens from the SO, gallbladder, common bile duct, and duodenum demonstrated a rich network of nerves, as suggested by light microscopy and confirmed by a myelin marker S-100. SO demonstrated very strong immunoreactivity for VIP, strong immunoreactivity for neuropeptide Y and galanin, moderate immunoreactivity for PHI and CGRP, and borderline immunoreactivity for bombesin and substance P. Serotonin and somatostatin immunoreactivity was also observed, not in the nerves, but in some of the epithelial cells. The gallbladder innervation was virtually identical to the SO innervation, whereas common bile duct and duodenal innervation were slightly different. To our knowledge this is the first time that galanin- and PHI-like immunoreactivities have been observed in the SO. Our observations suggest that these peptides, along with VIP, neuropeptide Y, and CGRP, might play a role in the neural control of biliary motility.
Animals↗
Prospective randomized trial of the effect of nifedipine on pancreatic irritation after endoscopic retrograde cholangiopancreatography.
Endoscopic retrograde cholangiopancreatography (ERCP) is complicated by acute pancreatitis in up to 12% of the examinations. One possible mechanism for this complication is the cannulation-induced sphincter of Oddi spasm with temporary pancreatic duct obstruction. Nifedipine is known to relax the sphincter of Oddi, thus possibly inhibiting or reducing post-ERCP +/- endoscopic sphincterotomy (EST) pancreatic irritation. To test this hypothesis 166 adult patients undergoing ERCP +/- EST were randomized to receive nifedipine (n = 82) 20 mg 3 times at 8-hour intervals during the day of ERCP +/- EST or placebo (n = 84) in a double-blind manner. Clinical pancreatitis developed in 6 patients (4%), in 3 patients in each group. Necrotizing pancreatitis developed in 3 patients, 2 (2%) in the nifedipine group and 1 (1%) in the placebo group. Overall 60 patients (36%) needed medication for post-ERCP +/- EST epigastric pain, 27 (33%) in the nifedipine group and 33 (39%) in the placebo group. Of the 87 patients, who did not need any pain medication before ERCP +/- EST, 34 (39%) needed pain medication after ERCP +/- EST. 14/47 (30%) in the nifedipine group and 20/40 (50%) in the placebo group (p = 0.044). Serum total amylase activity (median) increased from 189 U/l (range 39-11,950 U/l) before ERCP +/- EST to 299 U/l (range 43-11,824 U/l) at 12 h (p < 0.001) and 247 U/l (range 34-15,950 U/l) at 24 h (p < 0.001), with no differences between the two groups. Median serum C-reactive protein concentration and blood leukocyte count remained unchanged in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Abdominal Pain↗
Nifedipine for suspected type II sphincter of Oddi dyskinesia.
Endoscopic sphincterotomy may be the treatment of choice in type I sphincter of Oddi dyskinesia, but in type II dyskinesia the results are controversial, the complication rate may be high, and technically endoscopic sphincterotomy is not always possible. Nifedipine has been observed to relax the sphincter of Oddi and to enhance biliary drainage, especially in patients suffering from sphincter of Oddi dyskinesia. Therefore, nifedipine (10 mg, three times a day) was compared with placebo in treating suspected type II sphincter of Oddi dyskinesia in 13 cholecystectomized patients in a 16-wk study period in a double-blind "cross-over" manner. Daily, the patients completed a diary of the pains, need of pain medication, and headache. Clinical examinations and blood tests for liver chemistry were performed at 4-wk intervals. Nifedipine diminished the number of days on which the patients experienced biliary-type pains (10.5 +/- 8.6 vs. 5.8 +/- 4.1, p = 0.042), and the number of days when pain medication was needed was slightly reduced (5.2 +/- 3.9 vs. 3.6 +/- 3.2, p = 0.066). After the study, one patient preferred to undergo endoscopic sphincterotomy, eight patients preferred to continue with nifedipine, and four patients preferred analgesics only. Liver chemistry remained unchanged in this study. Also heart rate, blood pressure, and the number of days of headache were not different between the nifedipine and placebo periods. We conclude that nifedipine is well tolerated in patients with type II sphincter of Oddi dyskinesia, and nifedipine may be tried for reducing the number of painful days and need for analgesics in patients with this disorder.
Adult↗
Changes in biliary bacteria after endoscopic cholangiography and sphincterotomy.
This prospective study consisted of 32 patients. In each patient, bile was collected during two separate endoscopic retrograde cholangiopancreatographies (ERCP) to study changes in biliary bacteriology and cytology. The mean interval between ERCPs was 20 months (15-29 months). Twenty-three patients had gallstones in the gallbladder, bile ducts, or both. Nineteen of them had bactibilia compared to none of the 9 patients with normal ERCP (P less than 0.001). Fifteen patients had normal bile ducts in ERCP (Group 1). Four of these patients (27%) had bactibilia initially and 9 (60%) at follow-up (P = 0.069). Seventeen patients had bile duct stones and underwent endoscopic sphincterotomy (Group II). Fifteen of these patients (88%) had bactibilia initially, and 15 (88%) also had bactibilia at follow-up. Initially, anaerobic bacteria were detected in 37 per cent of Group I patients with bactibilia and in 50 per cent of Group II patients with bactibilia. At follow-up, the bile in Group I patients infrequently (11%) contained anaerobes, whereas in Group II patients anaerobes predominated (67%; P less than 0.011). Clear correlation between the biliary cytology and bacteriology could not be observed. The authors conclude that ERCP may result in increased incidence of long-term bactibilia and suggest that contamination occurred during ERCP. The bactibilia associated with bile duct stones does not subside after endoscopic treatment of the common duct stones.
Adult↗
A case control study of cigarette smoking and lung cancer in Luxembourg.
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Adult↗
Multimodal therapy for locally advanced breast cancer.
Thirty-one women with stage III breast cancer were prospectively treated with two cycles of cyclophosphamide (Cytoxan), doxorubicin hydrochloride (Adriamycin), fluorouracil, and tamoxifen citrate followed by a simple mastectomy with level I axillary dissection. Postoperatively, four additional cycles of the combination chemotherapy alternating with three cycles of 1500 rad (15 Gy) to the chest wall and lymphatics were given. Seventy-seven percent of patients had a greater than 50% reduction in tumor size after the initial chemotherapy. No tumor size progressed during therapy, and a single patient remained inoperable. Pathologic findings revealed nine patients with only microscopic residual tumor. Nuclear vacuolization was present in 42.8% of tumor cells after chemotherapy vs 14.2% of cells before chemotherapy. The mean follow-up for the groups is 24.3 months. To date, nine patients have had recurrence with only one isolated local recurrence. This therapy is effective in reducing primary tumor size and allows a limited mastectomy to be done with minimal morbidity.
Adult↗
Dynamic 3D-MR mammography: is there a benefit of sophisticated evaluation of enhancement curves for clinical routine?
The purpose of the study was to compare standard analysis with pharmacokinetic analysis of time-intensity curves in dynamic three-dimensional (3D) MR mammography (MRM) for their capability of differentiating benign from malignant disease. Dynamic MRM of the whole breast was performed at 1.0 T using an axial fast low-angle shot (FLASH) 3D sequence. For the standard evaluation, the enhancement of the first minute (E1) and the slope of enhancement from minute 2 to 10 (SE2-10) were calculated. For pharmacokinetic analysis, the amplitude of enhancement (A), distribution time (t21), and elimination time (tel) were computed. Sixty-two histologically verified lesions were evaluated. The standard evaluation methods yielded a highly significant difference between benign and malignant disease for E1 (P = .0008) and SE2-10 (P = .0001). The pharmacokinetic parameters gained similarly significant P values (A, P = .0014; t21, P = .0024; tel, P = .0001). Both standard and pharmacokinetic analysis concordantly discriminated between benign and malignant lesions in discriminant analysis. Compared with standard analysis, a pharmacokinetic analysis of time-intensity curves is not beneficial for routine clinical diagnosis.
Adolescent↗
Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis--a single-center randomized study.
Pancreatic infection is the main indication for surgery and the principal determinant of prognosis in acute necrotizing pancreatitis. Previous studies on the effects of antibiotics have not, however, uniformly demonstrated any reduction in the need for surgery or any decrease in mortality among these patients, although the incidence of pancreatic infections was significantly reduced. This single-center randomized study was designed to compare early vs. delayed imipenem treatment for acute necrotizing pancreatitis. Ninety patients with acute necrotizing pancreatitis (C-reactive protein > 150 mg/L, necrosis on CT) were randomized within 48 hours either to a group receiving imipenem (1.0 g plus cilastatin intravenously 3 times a day) or a control group. Not included were those who had been started on antibiotics at the referring clinic, those who were taken directly to the intensive care unit for multiorgan failure, and those who refused antibiotics or might have had adverse reactions. Thirty-two patients were excluded because they were over 70 years of age (not potentionally operable) or for any study violation. There were 25 patients in the imipenem group and 33 patients in the control group. The main end point was the indication for necrosectomy due to infection (i.e., after the initial increase and decrease, there was a second continuous increase in temperature, white blood cell count [> 30%] and C-reactive protein [> 30%], with other infections ruled out, or bacteria were found on Gram stain of the pancreatic fine-needle aspirate). In the control group, imipenem was started when the operative indication was fulfilled. Conservative treatment was continued for at least 5 days before necrosectomy. The study groups did not differ from each other with regard to sex distribution, patient age, etiology, C-reactive protein concentration, and extent of pancreatic necrosis on CT. Two (8%) of 25 patients in the imipenem group compared to 14 (42%) of 33 in the control group fulfilled the operative indications (P = 0.003). Nine patients in the control group responded to delayed antibiotics but five had to undergo surgery. Of those receiving antibiotics, 2 (8%) of 25 in the early antibiotic (imipenem) group needed surgery compared to 5 (36%) of 14 in the delayed antibiotic (control) group (P = 0.04). Two (8%) of 25 patients in the imipenem group and 5 (15%) of 13 patients in the control group died (P = NS [no significant difference]). Seven (28%) of 25 in the imipenem group and 25 (76%) of 33 in the control group had major organ complications (P = 0.0003). Based on the preceding criteria, early imipenem-cilastatin therapy appears to significantly reduce the need for surgery and the overall number of major organ complications in acute necrotizing pancreatitis, and reduces by half the mortality rate; this is not, however, statistically significant in a series of this size.
Adult↗
Post-ERCP pancreatitis: reduction by routine antibiotics.
Cholangitis and pancreatitis are severe complications of endoscopic retrograde cholangiopancreatography (ERCP). Antibiotics have been considered important in preventing cholangitis, especially in those with jaundice. Some have suggested that bacteria may play a role in the induction of post-ERCP pancreatitis. It is not clear, however, whether the incidence of post-ERCP pancreatitis could be reduced by antibiotic prophylaxis, as is the case with septic complications. In this prospective study, a total of 321 consecutive patients were randomized to the following two groups: (1) a prophylaxis group (n = 161) that was given 2 g of cephtazidime intravenously 30 minutes before ERCP, and (2) a control group (n = 160) that received no antibiotics. All patients admitted to the hospital for ERCP who had not taken any antibiotics during the preceding week were included. Patients who were allergic to cephalosporins, patients with immune deficiency or any other condition requiring antibiotic prophylaxis, patients with clinical jaundice, and pregnant patients were excluded. In the final analysis six patients were excluded because of a diagnosis of bile duct obstruction but with unsuccessful biliary drainage that required immediate antibiotic treatment. The diagnosis of cholangitis was based on a rising fever, an increase in the C-reactive protein (CRP) level, and increases in leukocyte count and liver function values, which were associated with bacteremia in some. The diagnosis of acute pancreatitis was based on clinical findings, and increases in the serum amylase level (>900 IU/L), CRP level, and leukocyte count with no increase in liver chemical values. The control group had significantly more patients with post-ERCP pancreatitis (15 of 160 in the prophylaxis group vs. 4 of 155 in the control group; P = 0.009) and cholangitis (7 of 160 vs. 0 of 155; P = 0.009) compared to the prophylaxis group. Nine patients in the prophylaxis group (6%) and 15 patients in the control group (9%) had remarkably increased serum amylase levels (>900 IU/L) after ERCP, but clinical signs of acute pancreatitis with leukocytosis, CRP reaction, and pain developed in four of nine patients in the prophylaxis group compared to 15 of 15 patients with hyperamylasemia in the control group (P = 0.003). In a multivariate analysis, the lack of antibiotic prophylaxis (odds ratio 6.63, P = 0.03) and sphincterotomy (odds ratio 5.60, P = 0.05) were independent risk factors for the development of post-ERCP pancreatitis. We conclude that antibiotic prophylaxis effectively decreases the risk of pancreatitis, in addition to cholangitis after ERCP, and can thus be routinely recommended prior to ERCP. These results suggest that bacteria could play a role in the pathogenesis of post-ERCP pancreatitis
Acute Disease↗
Association between common bile duct stones and treated hypothyroidism.
BACKGROUND/AIMS: The purpose of this study was to investigate the frequency of diagnosed hypothyroidism in patients with common bile duct stones. METHODOLOGY: The common bile duct stone group (Group I) consisted of all the patients who had verified gallstones in the common bile duct in endoscopic retrograde cholangiopancreatography during 1995. The control group (Group II) was matched for age, sex, and hospital admission. These patients did not have diagnosed gallbladder or common duct stones. In both groups there were 86 patients (56 women and 30 men). The median age in these groups was 73 (range: 22-92) years at the time of common bile duct stone diagnosis. Medical records of all patients were reviewed. RESULTS: In Group I the prevalence of previously diagnosed hypothyroidism was 7/86 (8%) compared with 1/86 (1%) in Group II (P = 0.01). Hypothyroidism was previously diagnosed only in the common bile duct stone patients (Group I) of over 60 years of age, where the prevalence was 7/66 (11%). In addition, we studied 36 consecutive gallbladder stone patients (Group III) of over 60 years, who had no evidence of common bile duct stones. Hypothyroidism had been diagnosed in them less frequently (2/36 = 6%) than in the age and hospital admission matched common bile duct stone patients (P = 0.01). Other diagnosed endocrine disorders did not differ between the study groups. CONCLUSIONS: There is a significant association between the common bile duct stones and previously diagnosed hypothyroidism. There stronger association between the common bile duct stones and hypothyroidism compared to gallbladder stones and hypothyroidism suggests a mechanism other than merely the cholesterol metabolism mediated mechanism. The 11% prevalence of previously diagnosed hypothyroidism in the common bile duct stone patients of over 60 years of age suggests all patients with common bile duct stones be screened for current thyroid dysfunction.
Adult↗
Twenty to thirty year follow-up after cholecystectomy.
BACKGROUND/AIMS: We studied retrospectively the need for re-examinations and re-operations, the development of alimentary tract cancer, and the occurrence of abdominal symptoms 20-30 years after elective cholecystectomy. MATERIAL AND METHODS: Between 1963 and 1973 296 patients (73 males and 223 females) were treated by cholecystectomy. The indication was biliary colics plus stones in gallbladder. Patients with biliary-enterostomy, sphincteroplasty or synchronous extrabiliary operations were excluded. Retained bile duct stones were excluded by cholangiography. Medical records of all patients, death certificates of the patients who had died during the follow-up (n = 74), and the autopsy findings of autopsied patients (n = 29) were reviewed. The living 220 patients were interviewed by a structured questionnaire a median of 26 years after the operation. RESULTS: Patients were divided into two groups: Group I (172 patients) underwent cholecystectomy only and Group II (122 patients) underwent cholecystectomy and common duct stone extraction. During the follow-up, 25 patients (9%) underwent examinations for biliary colics and 12 (4%) were re-operated, 10 during 1-5 years after cholecystectomy. Both the examinations and re-operations were more common in Group II than in Group I (p < 0.005). Eight patients developed alimentary tract cancer during the follow-up. Thirty-nine per cent of patients reported abdominal symptoms, 20% having had these already prior to cholecystectomy. Abdominal pain was reported by 21%, distention by 20%, heart burn 16%, obstipation 14%, and diarrhea by 11%. Abdominal pain and diarrhea occurred more frequently in Group I than in Group II. CONCLUSION: Recurrent biliary colics and stones in the common bile duct are extremely rare later than five years after cholecystectomy and are not expected unless the patients have also initially had common duct stones. One third of patients suffer from other abdominal symptoms.
Case-Control Studies↗
The value of the endoscopic pancreatogram in peritoneal or pleural pancreatic fistula.
Endoscopic retrograde pancreatogram (ERP) has been recommended in patients with suspected pancreatic fistula to visualize the fistula tract and the ductal anatomy. Recently we have treated five men with chronic alcoholic pancreatitis complicated by pancreaticopleural or pancreaticoperitoneal fistula. The limited value of ERP in these patients is described. Computed tomography (CT) demonstrated dilated pancreatic duct (3 patients) or a pseudocyst (2 patients). A fistula tract protruding into the chest was detected by CT in two patients. In ERP the two pseudocysts could not be visualized. In none of the five patients could the fistula tract be visualized. Instead, the main pancreatic duct was completely occluded in the head of the pancreas in all five patients. The drainage of the pancreatic juice into the intestine was secured surgically by a jejunal Roux-Y loop connected to the pancreatic duct opened from the tail to the most proximal ERP demonstrated stricture (Puestow-type operation, 4 patients) or to the leaking pseudocyst (1 patient). During the follow-up of 3-24 months pleural or peritoneal effusions have not recurred. The role of ERP in a patient with a pancreatic fistula into the pleural or peritoneal cavity is to localize the site of the duct obstruction, whereas the demonstration of the distal duct anatomy or the fistula tract are of less importance.
Adult↗
Staging of abdominal cancer by local anesthesia outpatient laparoscopy.
BACKGROUND/AIMS: Our aim was to review the results of one trocar staging laparoscopies performed under local anesthesia in out patients with intra-abdominal cancer. MATERIALS AND METHODS: Two hundred fifteen patients with intra-abdominal cancer (predominantly esophagogastric and pancreatohepatobiliary) underwent one trocar staging laparoscopy on lidocain infiltration anesthesia under conscious sedation. In 43 patients computed tomography (CT) or ultrasonography (US) had raised a suspicion of hepatic metastases, but percutaneous needle biopsy had failed to confirm it; 172 patients had negative CT or US. Peritoneum and liver were examined and biopsies were taken under direct laparoscopic control. RESULTS: Fourteen patients (7%) received narcotics during the 2-6 hour observation. Mortality was zero. Complications occurred in 5 patients (2%): 1 small bowel perforation (operated), 1 bleeding from the abdominal wall, 1 acute atrial fibrillation, and 2 wound infections. In 79 patients histology demonstrated hepatic or peritoneal metastases. Out of 136 patients 123 were operated in whom laparoscopy did not demonstrate metastases. Thirty-eight of these were unresectable at laparotomy: Five patients (4%) had peritoneal or liver metastases and 33 (27%) proved locally inoperable. The sensitivity of laparoscopy to ascertain peritoneal or liver metastases was 94%. CONCLUSIONS: We conclude that one trocar local anesthesia outpatient laparoscopy is a fairly safe and effective method to detect peritoneal and liver metastases in abdominal cancer.
Abdominal Neoplasms↗
Distribution of local anesthetic solution in retromediastinal block. Preliminary experimental results.
BACKGROUND AND OBJECTIVES: Interpleural anesthesia blocks pain perception from the thoracoabdominal wall without impairment of leg function. Bilateral interpleural anesthesia is not recommended because of possible bilateral impairment of respiratory function. Infiltration of the retromediastinum with local anesthetic might cause bilateral thoracoabdominal somatic block and block of sympathetic afferents from the abdominal cavity without impairing respiration. METHOD: Distribution of stained fluid was studied after injection into the retromediastinum through a catheter placed about 10 cm cephalad to the diaphragm via the esophageal hiatus in three human cadavers of normal size and in six anesthetized pigs of 20-30 kg. In the pigs serum levels of bupivacaine were measured after injection of 10 mL of 0.5% bupivacaine stained with 1 mL of methylene blue. RESULTS: The injected Dye stained intercostal nerves 6-11 in cadavers and 5-12 in pigs symmetrically on both sides, along with the adjacent parts of the sympathetic chain and both vagal nerves but not the phrenic nerves. During the sampling period of 50-60 minutes, bupivacaine serum concentrations rose slowly to a maximum of 4.2 micrograms/mL. CONCLUSIONS: Block of pain perception from the abdominal wall and cavity is possible by injection of local anesthetic into the retromediastinum via a catheter introduced through the esophageal diaphragm hiatus. The block would not be expected to impair respiratory or leg function. Its efficacy and safety have yet to be established.
Adult↗