Prevention of regurgitation in patients with subcutaneous oesophageal grafts
Bibliographic record
Abstract
We would like to increase awareness of a cohort of patients for whom cricoid pressure during rapid sequence induction would be ineffective in preventing regurgitation. For these patients an alternative technique needs to be used. First described in 1911 by Georg Kelling 1, colon interposition grafting as an oesophageal substitute is used for a variety of indications including oesophageal atresia, corrosive pharyngo-oesophageal strictures and malignancy. There are a number of routes through which the conduits are placed, including the posterior mediastinum, retrosternally and subcutaneously. The subcutaneous route is chosen when the oesophageal bed and retrosternal routes are not available, for example following previous oeosophagectomy, sternotomy for coronary artery bypass grafting or extensive mediastinal radiotherapy. The upper gastrointestinal surgeons at our hospital carry out approximately six subcutaneous colon interposition procedures annually. Sellick's manoeuvre 2 to reduce the incidence of regurgitation during rapid sequence induction relies on the patent gastrointestinal tract's being posterior to the cricoid ring. Magnetic resonance imaging studies 3 have identified the hypopharynx as the area compressed between the cricoid ring and vertebral body. In the case of subcutaneous placed grafts, the normal hypopharynx and oesophageal anatomy is disrupted. A barium swallow radiograph (Fig. 2) demonstrates the suprasternal route taken by the graft and the proximal anastomosis to the pharynx, with no portion of the graft posterior to the larynx. Cricoid pressure would have no effect in controlling reflux of gastric contents. In these patients the lumen of the graft can be occluded by direct pressure over the graft against the anterior chest wall using the palm of the hand (Fig. 3). This is the technique we use and which we would recommend for rapid sequence induction in patients with subcutaneously placed oesophageal substitutes.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".