The emptying, acid secretion, mucosal changes, and duodenogastric and gastroesophageal reflux of the intrathoracic stomach were studied in 12 patients together with the clinical course 6–12 months after esophageal replacement. Although no pyloroplasty had been performed, the emptying of a semisolid meal from the interposed stomach was significantly accelerated compared to the controls. No residual food was found in the stomach at endoscopy after an overnight fast. Distinctly accelerated gastric emptying correlated with spontaneous duodenogastric reflux across the denervated pylorus. Despite a persistent acid secretion of the vagotomized intrathoracic stomach, no pathologic gastroesophageal reflux and no esophagitis were found proximal to the cervical anastomosis. Gastric biopsies mostly revealed mild gastritis of the antral mucosa, whereas metaplasia was rare. The intrathoracic stomach does not need a drainage procedure to facilitate semisolid emptying. Postoperative reflux esophagitis is prevented by complete intrathoracic stomach transposition with cervical esophagogastrostomy.

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Slowing of venous return is, in addition to endothelial damage and hypercoagulability, one of the decisive factors in the development of thrombi. This is especially so in operated patients with loss of vessel tone caused by general anaesthesia. The radiofibrinogen test was used on a group of 106 patients to check whether the administration of dihydroergotamine, which produces vasoconstriction particularly of the venous channels, can bring about a reduction in the incidence of postoperative thrombo-embolism. There was a statistically (variance analysis) highly significant difference in the average thrombosis rate between treated (8.8%) and untreated (34.7%) patients. In patients especially at risk, the rate was more than three times as high in the untreated group (39.5% and 12.9%, respectively). In low-risk patients the rate actually dropped to zero (from 20%).

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751phlebography. While in the Fragrnin group there were no positive tests for thrombosis, in the heparin-DHE group there were 3 (2 superficial thromboses and 1 deep vein thrombosis). In the Fragmin group, there was more blood loss intraoperatively and less postoperatively than in the heparin-DHE group. The plasma anti-X a activity was significantly higher in the Fragrnin group. The antithrombotic effect of 5,000 anti-Xa-U of LMW heparin daily is as high as that of the combination of 5,000 U-heparin with 0,5 mg DHE twice daily.Zusammenfassung. In einer kontrollierten, randomisierten Studie wurde die Wirksamkeit von niedermolekularem Heparin (Fragmin®) im Vergleich zur Kombination Heparin + DHE an 98 Patienten mit Hilfe der Phlebographie gepriift. In der Fragmin-Gruppe traten keine, in der Heparin-DHE-Gruppe 3 Beinvenenthrombosen auf (2 oberflfichliche, 1 tiefe). Der intraoperative Blutverlust war in der Fragrnin-Gruppe deutlich h6her, der postoperative geringer als in der Heparin-DHE-Gruppe. Die Anti-F-Xa-Aktivit~t lag signifikant h6her bei Fragmin. Niedermolekulares Heparin ist in einmaliger t/iglicher Dosis von 5000 Anti-Xa-U ebenso effektiv wie die Prophylaxe mit 2 x 5000 E Heparin + 0,5 mg DHE. Summary.In a randomized prospective double-blind study, low-molecular-weight (LMW) heparin 1500 IE 1 x daily was compared to standard heparin, 5000 IE 3 x daily. Two hundred patients aged 50 years or older were included. The diagnosis of deep venous thrombosis (DVT) was established by 125i_fibrinogen testing. DVT developed in 11 patients (11%) from each group. LMW heparin is at least as effective as standard heparin in preventing DVT. There are also fewer hemorrhagic complications and hematomas.

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Dihydroergotamine (DHE) is known to enhance the effect of low-dose heparin in the prevention of postoperative thromboembolism. In order to determine whether low-dose heparin can be reduced without decreasing the prophylactic efficacy, 350 fully randomized patients undergoing major abdominal surgery were studied by the 1-125-fibrinogen-uptake-test (RFUT) and repeated lung perfusions scintigraphy receiving either 5000 IU of heparin or 2500 IU of heparin + 0.5 mg DHE b.i.d.Results: Heparin 5000: 15 RFUT-positive (9.3%), 5 with lung perfusion defects (3.1%), 40 with haemorrhagic complications (24.8%); Heparin 2500 + DHE: 13 RFUT-positive (8.0%), 4 with lung perfusion defects (2.5%), 8 with haemorrhagic complications (4.9%), the difference in bleeding complications is highly significant (p < 0.001).Conclusions: The combination of heparin 2500 IU + DHE 0.5 mg b.i.d. proved equivalent to heparin 5000 IU b.i.d. in terms of antithrombotic efficacy, whereas bleeding complications due to prophylaxis (wound haematoma, postoperative bloodloss, reoperations because of haemorrhage) were significantly reduced. Altogether this combination turns out an important progress in the postoperative thromboprophylaxis.

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