Results Significantly more patients were found to have neuropsychological deficits in the group without the arterial line filter at both 8 days (P<.05) and 8 weeks (P<.03) after surgery. In addition, more "soft" neurological signs were found in the nonfiltered group 24 hours after surgery (P<.05). More high-intensity transcranial signals were found in the nonfiltered group, and the number of high-intensity transcranial signals was found to be related to the likelihood of a patient having a neuropsychological deficit at 8 weeks.Conclusions These data suggest that neuropsychological deficits after routine cardiopulmonary bypass are related to the number of microemboli delivered during surgery. Furthermore, the numbers of microemboli may be reduced by including a 40-^m filter on the arterial line. (Stroke. 1994;25:1393-1399

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 39. See the HTA programme website for further project information.

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Arterial microemboli, which may be reduced by arterial line filtration, have been proposed as a factor contributing to cardiopulmonary bypass (CPB)-related cerebral dysfunction. The authors report on a study investigating the effects of arterial line filtration on the incidence of microemboli and the neuropsychological outcome in patients undergoing coronary artery surgery. Patients were randomized to filtered (40 micron) and nonfiltered CPB. Change from preoperative neuropsychological performance was assessed eight weeks after surgery by a battery of ten tests plus a mood state assessment. Perfusion technique (pressure at UNIVERSITY OF TOLEDO LIBRARIES on March 15, 2015 ves.sagepub.com Downloaded from 35 > 50mmHg, flow 1.8-2.4L/m 2 /min) was standardized and continuously monitored. Transcranial Doppler measured middle cerebral artery blood velocity and the incidence of microembolic events (MEE). Forty patients (median age fifty-six years, range forty-three to seventy) have completed the protocol. MEE occurred in all patients during aortic cannulation and at inception of bypass. During bypass, patients with filtered CPB had fewer MEE (0-10 per thirty minutes) than nonfiltered CPB patients (30-> 250 per thirty minutes) did. Seven of 20 nonfiltered CPB patients showed soft neurologic signs on the first postoperative day compared with 3/20 in the filtered CPB group (P = 0.27, Fisher's). The filtered CPB patients performed better on a verbal memory test (P < 0.01, Wilcoxon) at eight weeks than the nonfiltered CPB group did.

To observe and quantify cerebrovascular microembolic events in the central nervous system during cardiopulmonary bypass, 40 patients having elective uncomplicated coronary surgery had retinal fluorescein angiograms 5 min before bypass was discontinued. Each patient also had 10 neuropsychological tests before and after surgery. A Harvey H1700 bubble oxygenator was used for 23 patients and a Cobe CML sheet membrane oxygenator was used for 17 patients. All 23 (100%) of patients in the bubble oxygenator group had retinal microvascular occlusions consistent with microembolism compared to 8/17 (47%) in the membrane oxygenator group (P less than 0.001). In those retinas with occlusions, the mean resultant area of non-perfusion was less in the membrane oxygenator group (0.11 mm2; n = 8) than in the bubble oxygenator group (0.29 mm2; P less than 0.01). Arterial PO2 levels during bypass were similar in both groups at moderate hypothermia, but the mean PaO2 during rewarming was higher in the bubble oxygenator group (27 kPa) than in the membrane group (13 kPa; P less than 0.001). Neuropsychological deficits were more common and more severe after bubble oxygenation than after membrane oxygenation, but in this small patient group, the difference was not statistically significant. We conclude that flat sheet membrane oxygenation during cardiopulmonary bypass may confer significant protection against cerebrovascular microembolism.

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Aim: The aim of this retrospective analysis was to exclusively present the surgical results of patients with type-I–III adenocarcinomas of the esophagogastric junction thereby providing a basis for comparison with other approaches. Methods: 56 patients with Barrett’s carcinomas and 74 patients with cardial and subcardial tumors were operated on and evaluated. The surgical procedure for type-II/III carcinomas was identical: total gastrectomy, omentectomy and splenectomy with lymph node dissection after a combined left thoraco-abdominal incision. Both tumor entities were summarized into 1 group and compared with the results of surgery for Barrett’s carcinomas: subtotal esophagectomy and proximal stomach resection with lymph node dissection after right thoracotomy and an additional abdominal incision. Results: In 93% of all patients an R0 resection was possible. In patients with Barrett’s carcinomas pulmonal complications (41%) were the predominant postoperative problems. The 30-day lethality (5.3%) was higher in the group of patients with type-I carcinomas compared to those with type-II/III carcinomas (1.4%). Tumor infiltration and nodal involvement determined the prognosis after R0 resection. The presence of Barrett’s mucosa in type-I adenocarcinomas and the histological assessment according to Lauren’s classification into type-II/III carcinomas also influenced the long-term prognosis. Conclusion: After R0 resection it is not the tumor location but tumor infiltration, lymph node status and a differentiated histological assessment that determine the prognosis of patients with adenocarcinomas of the esophagogastric junction.