Perumbilical portal vein catheters and arterial and central venous catheters were inserted in 16 patients recovering from trauma or other shock-producing events, and in 5 patients who later developed shock. This permitted serial measurement of blood gases, pH, and the levels of ammonia, lactate and certain other metabolites in all three circulatory systems simultaneously. Nine of the trauma patients were never in shock, had no liver disease or injury and consequently formed a baseline group for comparison with the shock patients. In the shock patients there was a significant degree of hypoxemia in the portal venous blood and an increase in the arterialportal oxygen saturation difference. Their portal venous blood showed a lower pH and a higher pCO(2) than did the portal blood of the patients who had never been in shock. In 3 of the 4 shock patients who died, the total blood lactate showed a greater increase in portal venous than in the arterial or central venous blood. In shock there was also an increase in portal venous blood ammonia which was later accompanied by increments in arterial and central venous blood ammonia. This suggests impairment of hepatic urea synthesis, allowing escape of ammonia through the liver. These phenomena, when added to the finding previously reported of an elevated portal venous pressure in some shock patients, lend support to the hypothesis that in certain cases of shock there is increased impedance to flow of portal blood through the liver with resultant stasis in the portal-splanchnic bed and ischemichypoxic hepatocellular injury.
Twelve years of experience have now been gained with a new therapeutic approach to car- cinoma of the esophagus. In this approach, the pri- mary goal of treatment is palliation, with cure an important but secondary objective. Carcinomas in the upper third of the esophagus are treated by radiation therapy unless there is se- vere obstruction or tracheal invasion, in which case colon interposition is performed. Limited resection with esophagogastrostomy is performed through a right thoracotomy and midline laparotomy for neoplasms in the middle third of the esophagus and through a left thoracotomy for carcinomas in the lower third. Since 1969, 161 patients have been evaluated, of whom 107 (66%) have been managed according to the new protocol. Twenty patients with carcinomas of the upper third of the esophagus were treated primarily by radiotherapy and 7 by colon interposi- tion. Resection was performed in 78 of the 80 pa- tients with carcinomas of the middle and lower thirds. There were 9 operative deaths (10%). Palliation, of superior quality to that obtained by previous methods, was provided to 95 of the 107 pa- tients. Survival also is at least on a par with that ob- tained before. In 1972, we (l) reported the initial results of a new therapeutic approach to squamous cell car- cinoma of the esophagus. It was based on the premise that this tumor usually is incurable and that the primary therapeutic objective should be palliation, with cure an important but sec- ondary goal. This treatment plan was adopted in 1969 because of the dismal results that had been obtained during the preceding 12 years.
