In the past 10–15 years portacaval shunt surgery has found decreasing popularity in the treatment of acute and chronic bleeding of esophageal varices because injection sclerotherapy, transection procedures, and liver transplantation now offer convincing therapeutic alternatives (Häring and Karavias 1990; Siewert and Feussner 1990). This may explain why a very astonishing operative procedure of shunt surgery developed in China — the direct mesoeaval shunt — has not yet found wide acceptance. The Medline System does not contain Single publication about this special operative technique before 1975. We describe here our experiences with the direct mesoeaval shunt.

Increasing knowledge about immunological [6, 18], oncological [4, 5. 17], and infectious [2, 12, 19] risks when transfusing blood have altered attitudes and indications of blood-transfusions as well as the effort to reduce the loss of blood intraoperatively and postaperatively [1]. Recently, attention has been particularly focussed on the potential risk of HIV-infection. The high risk of hepatitis infection after transfusion is well-known; it amounts to 4 %, corresponding to 25. 000 infected patients in the Federal Republic of Germany annually [13, 15].

We report two cases of primary malignant melanoma of the esophagus. Both were female, 83 and 68 years of age. Both had metastatic spread of the disease at the time of first treatment, either in regional lymph nodes or organ involvement. One patient underwent resection of the tumor (partial esophagectomy). The second patient is alive 22 months postoperatively with metastatic tumor (12/1989), the first died one year after diagnosis. Prognosis of primary melanoma of the esophagus is poor. Though, resection of the tumor is the most promising therapy.

We report two cases of primary malignant melanoma of the esophagus. Both were female, 83 and 68 years of age. Both had metastatic spread of the disease at the time of first treatment, either in regional lymph nodes or organ involvement. One patient underwent resection of the tumor (partial esophagectomy). The second patient is alive 22 months postoperatively with metastatic tumor (12/1989), the first died one year after diagnosis. Prognosis of primary melanoma of the esophagus is poor. Though, resection of the tumor is the most promising therapy.

Revascularization of central occluded supraaortic vascular branches is more and more successfully done by extra-anatomic junction to the nearest other supraaortic vessel. In case of extreme stenosis of all supraaortic donor vessels intrathoracic surgery may be excluded in poor risk patients. The only possibility of extra-anatomic junction remains connection to iliaco-femoral vessels according to the well known femoro-axillary bypass. Showing two typical cases, this method is demonstrated proving its importance in elective and emergency surgery. The first patient (67 yrs. of age) showed an acute complete ischemia of the right arm due to obstruction of the subclavian artery distal of the origin of the truncus brachiocephalicus. Emergency operation was performed, and revascularization was achieved by femoro-axillary bypass because of biological inoperability to all other orthopic procedures. The second case is of a 66 yrs. old patient with abdominal aortic aneurysm and multiple stenoses of the supraaortic vessels. The abdominal aortic aneurysm was electively operated upon, and during the same operation the cerebral circulation was hemodynamically improved by performing a femoro-subclavian bypass. In considering these two cases, indications, risks and benefits of extra-anatomic revascularization procedures are discussed.

Die vorliegende Kasuistik beschreibt eine im Erwachsenenalter erstmalig sympt oma tisch gewordene. thorakale Aortenmehrfachstenose . Die Angiokardiographie ergab eine Dilatation des Trun cus brachioceph alicus . eine Stenosierung des Aortenbogens zwischen A. carotis sinistra und A.subclavia stntstra mit Lumeneinengung der A. subclavia im Abgangsbereich und eine zusä tzliche langstreckige Aortenisthmusstenose loeo typico ohne assoziierte kardiale Fehlbildung. In extrakorporaler Zirkulation wurde der gesamte betroffen e Aortenabschn itt mitte ls transperikardialem aorto-aortalem Protheseninterponat umgangen. Diese Beobachtung zeigt exemplarisch, daß auch Mehrfachstenosen des Aortenbogens und/oder der thorakalen Aorta mit geringem oper ativen Risiko und gutem Spätergebnis korrigiert wer den könn en.

Revascularization of central occluded supraaortic vascular branches is more and more successfully done by extra-anatomic junction to the nearest other supraaortic vessel. In case of extreme stenosis of all supraaortic donor vessels intrathoracic surgery may be excluded in poor risk patients. The only possibility of extra-anatomic junction remains connection to iliaco-femoral vessels according to the well known femoro-axillary bypass. Showing two typical cases, this method is demonstrated proving its importance in elective and emergency surgery. The first patient (67 yrs. of age) showed an acute complete ischemia of the right arm due to obstruction of the subclavian artery distal of the origin of the truncus brachiocephalicus. Emergency operation was performed, and revascularization was achieved by femoro-axillary bypass because of biological inoperability to all other orthopic procedures. The second case is of a 66 yrs. old patient with abdominal aortic aneurysm and multiple stenoses of the supraaortic vessels. The abdominal aortic aneurysm was electively operated upon, and during the same operation the cerebral circulation was hemodynamically improved by performing a femoro-subclavian bypass. In considering these two cases, indications, risks and benefits of extra-anatomic revascularization procedures are discussed.

Die vorliegende Kasuistik beschreibt eine im Erwachsenenalter erstmalig symptomatisch gewordene, thorakale Aortenmehrfachstenose. Die Angiokardiographie ergab eine Dilatation des Truncus brachiocephalicus, eine Stenosierung des Aortenbogens zwischen A. carotis sinistra und A. subclavia sinistra mit Lumeneinengung der A. subclavia im Abgangsbereich und eine zusatzliche langstreckige Aortenisthmusstenose loco typico ohne assoziierte kardiale Fehlbildung. In extrakorporaler Zirkulation wurde der gesamte betroffene Aortenabschnitt mittels transperikardialem aorto-aortalem Protheseninterponat umgangen. Diese Beobachtung zeigt exemplarisch, daß auch Mehrfachstenosen des Aortenbogens und/oder der thorakalen Aorta mit geringem operativen Risiko und gutem Spätergebnis korrigiert werden können.