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Compromised mesenteric blood flow causes significant metabolic and histologic changes. These local changes could not be detected by arterial or mixed venous lactate concentrations, pH, and PCO2 determinations. Under closed-system conditions, mesenteric CO2 accumulation causes an impairment of the CO2-HCO3- buffer, resulting in an unchanged cHCO3-. With impaired mesenteric perfusion, only intramucosal PCO2 alterations occur and an intramucosal pH calculation based on systemic cHCO3-changes is not necessarily correct. Therefore, the only parameter of importance is the intraluminal measurement of intramucosal PCO2 that can reflect isolated mesenteric changes. Thus, we recommended abolishing the terms "intramucosal pH measurement" and "gastric tonometry" and propose using the definition "intramucosal PCO2 measurement."

Askin tumors are highly malignant small-round-cell tumors of the thoracopulmonary region, which occur rarely. Therefore, we report on our experiences with eight patients (5 male, 3 females), who were treated in our department between 11'94 and 10'97 (age: 9-40 years, mean age: 20.5 years). All Askin tumors were diagnosed by histological and immunohistochemical examinations as well as molecular genetic proof of characteristic translocations. In all patients, the tumor arose from the chest wall, infiltrating adjacent ribs and parts of the lung. At the time of first diagnosis, five patients did not reveal any metastases. One patient suffered from intrapulmonary metastases and two patients from an infiltration of the diaphragm and of adjacent vertebral bodies. Treatment consisted of a pre- and postoperative (radio-) chemotherapy according to the EVAIA protocol and a radical tumor resection in all patients. The postoperative course was uneventful in seven patients, one patient suffered from pneumonia after multiple wedge resections for intrapulmonary metastases. Four patients, in whom primary tumor resection was complete, are alive 14, 20, 35 and 84 months after first diagnosis - only one patient had to undergo a second operation for a local relapse 17 months after first diagnosis. The other 4 patients, who suffered from a very extensive primary tumor, expired 13, 17, 18 and 39 months after the diagnosis was made. Our data demonstrate that Askin tumors require an aggressive multimodality treatment consisting of pre- and postoperative chemotherapy, radical surgical resection and postoperative irradiation, which may be performed preoperatively in selected cases, too.

Escalating medical costs, limitation of resources and the necessity to provide cost-effective medical care have created a need for systematic risk stratification and cost-benefit analyses in the background of an ongoing discussion. Results of heart surgery in octogenarians have been evaluated in a prospective single-center, study since 1990. 101 consecutive patients (55/ 101 = 54.5% female) aged 80 years and above (median: 81 years; interquartile range [IQR]: 80.0-82.5, total range [TR]: 80-92 years) undergoing open heart surgery at our institution between January 1990 and March 1996 were included into this prospective study. Prior to surgery, most patients were severely symptomatic being in functional NYHA classes either III (56.4%) or IV (31.7%). 61/101 (60.4%) patients underwent isolated coronary artery bypass grafting (CABG), 23 (22.8%) had aortic valve replacement (AVR), 14 patients (13.9%) had CABG combined with AVR or double valve replacement and 3 (3.0%) had mitral valve repair. Follow-up (median: 23.0 months. IQR: 10.5-39.0, TR: 1-72) was focused on long-term morbidity and quality of life. The impact of preoperative and operative risk factors on morbidity and mortality was determined by uni- and multivariate statistical analysis. The 30-days overall mortality in this study was 7.9%. The postoperative course was uneventful for 27 (26.7%) of our patients. Univariate risk factors of postoperative mortality were: left main stem disease (p < or = 0.044), ejection fraction < 45% (p < or = 0.006), preoperative intensive care unit (ICU) (p < or = 0.002), urgent or emergency operation (p < or = 0.034). The only independent predictor of operative mortality was preoperative ICU-stay (p < or = 0.008). Significant risk factors for the number of postoperative complications in the multivariate analysis were: prior stroke (p < or = 0.04), diabetes mellitus (p < or = 0.02), New York Heart Association (NYHA) class IV symptoms (p < or = 0.002) and prolonged cross-clamping time (p < or = 0.001). Mean postoperative length of stay in the ICU was 3.9 +/- 3.9 days. Late morbidity was not related to postoperative complications. Cumulative survival was 87.9%, 79.5% and 72.9% at one, two or five years, respectively. After hospital discharge, 67/93 patients (82.8%) were in NYHA functional class I or II. Cardiac surgery in very elderly patients can be performed with acceptable operative risk and a favorable long-term outcome. The individual patient risk-profile including significant co-morbid conditions and severity of the heart disease predicts not only survival but the extent of perioperative morbidity.

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