Tuesday Morning, June 1, 1948

9:00 A.M. Scientific Session.

13. The Clinical Use of a Prosthesis to Prevent Overdistension of the Remaining Lung Following Pneumonectomy.

Julian Johnson and (by invitation)

Charles K. Kirby, Philadelphia, Pa.

The experimental data of Cournand and his co-workers have suggested that pulmonary function is decreased by the overdistension of the remaining lung following a pneumonectomy. This tends to confirm the clinical impression of some surgeons that the patient does best who has had a thoracoplasty to prevent this "compensatory emphysema." It seemed desirable to be able to achieve this result by some means less radical than a thoracoplasty. Therefore, an effort has been made to obtain a prosthesis with which the pleural cavity may be filled at the time of pneumonectomy, thereby preventing overdistension of the remaining lung.

Experimental studies in dogs have indicated that lucite balls may be used for this purpose. The effect of these balls has been observed in dogs for over one year. The shift of the mediastinum is prevented and there is a minimum foreign body reaction. This procedure has now been used upon six patients subjected to pneumonectomy. The advantages and disadvantages of this type of prosthesis will be discussed.

14. An Evaluation of Extrapleural Pneumonolysis With Lucite Plombage.

Josiah C. Trent (by invitation), James D. Moody

(by invitation), Durham, N. C., and Joseph S. Hiatt, Jr.

(by invitation), McCain, N. C.

1. Fifty-one cases operated from one year and four months to two years and seven months prior to this report have been presented in which extrapleural pneumonolysis with lucite plombage has been attempted or carried out. Nine cases (17.6 per cent) are improved, five (9.8 per cent) unimproved, eighteen (35.3 per cent) worse, fifteen (29.2 per cent) dead and four not followed.

2. Lucite plombage must be a definitive procedure for once the spheres are inserted they are extremely difficult to remove unless the surrounding tissue is liquified by infection.

15. Experimental and Clinical Study of Collapse Therapy Using Fiberglas Wool and Fabric.

Thomas J. O'Neill and (by invitation) Hector P. Redondo

and Robert G. Trout, Philadelphia, Pa.

Various types of collapse therapy procedures are discussed. It is felt that improvement over existing technics can be made. Two Fiberglas products are presented with this in mind, and their suitability as prosthetic agents examined.

The first product, Fiberglas wool, has been used as a "filler", in a series of experimental animals (dogs), to fill completely the tissue dead space resulting from extrapleural pneumonolyses. This was done by packing the extrapleural space with the wool and closing the wound in layers over the packing.

The second product, Fiberglas woven fabric has been used as a "container", in a series of experimental animals (dogs), to cover a lobe completely which had deliberately been subjected to atelectasis. This maintained the collapse by successfully resisting re-expansion. The "container", or bag was fashioned at the time of operation and sutured securely. The remaining lobe or lobes were allowed to re-expand immediately bringing about a selective collapse of the treated lobe.

The animals were followed by X-ray, and were sacrificed at selected intervals, and the condition of the fabric, pleura, parenchyma and vascular supply was investigated both grossly and microscopically. Photographs were made for comparative demonstrations.

A clinical review of nine patients was made. Seven had the wool used as extrapleural packing, and two, had the fabric used as a lobe container in deliberate selective collapse following pneumonolysis done by the open technic.

The results of these studies are regarded as very satisfactory and show promise of useful and more widespread applications.

16. Intrathoracic Meningocele.

Francis S. Byron, Los Angeles, Calif., and (by invitation)

Emery E. Alling, Battle Greek, Mich., and Paul G. Samson,

Oakland, Calif.

A review of the literature on intrathoracic meningocele reveals only three proven, and two probable cases of this anomaly. None of these reports appeared in the American Literature. While this lesion would appear to be extremely rare, it may be suspected to occur more often than is realized since each of the authors have encountered, and operated upon, a case within the past year.

From a diagnostic standpoint the anomaly may closely simulate intrathoracic neurofibromata and this, in fact, was the preoperative diagnosis in each instance. In the X-ray they are seen as smoothly outlined or lobulated posterior mediastinal masses. There may be enlargement of an intervertebral foramen, absorption of adjacent ribs and destruction of vertebrae. The further similarity of intra-thoracic meningocele to intrathoracic neurofibroma is the frequent association of neurofibromatosis. The only procedure that offers a good chance of differential diagnosis is intraspinal injection of a radio-opaque medium and positioning of the patient so as to demonstrate the meningeal communication. Inasmuch as excision of the meningocele is inadvisable in many instances, the differential diagnosis is essential.

17. Use of Pedicle Tube Flap in Carcinoma of Upper Esophagus.

Eugene Bricker (by invitation)

and Thomas H. Burford, St. Louis, Mo.

Experiences with carcinoma of the upper esophagus are presented. A rational plan of attack on these lesions is believed to have been worked out. Since the lymph drainage of the upper esophagus is, to a large degree, through the lower chain of cervical nodes bilaterally, a valid procedure for the treatment of cancer in this region must embody radical bilateral neck dissection. Procedures failing to take this into account are unsound from the standpoint of cancer surgery. A description is presented with illustrative slides and photographs of a procedure combining radical neck dissection with anterior thoracotomy. Satisfactory staged reconstruction of the upper esophagus is obtained by the use of a pedicle tube graft which is anastomosed directly to the thoracic esophagus in the superior mediastinum with reestablishment of normal deglutition.

18. Transthoracic Esophago-Jejunogastrostomy for High Stricture of the Esophagus.

Albert Wilson Harrison, Galveston, Tex.

After complete stricture of the esophagus, gastrostomy feeding is a poor substitute for normal eating. Accumulations in the pharynx are a constant threat to the respiratory system in addition to the annoyance of frequent spitting.

Two boys, both aged three years, had complete cervical strictures from drinking lye and were subject to repeated attacks of pneumonitis. A segment of jejunum was substituted for the resected esophagus in each case. The procedure was successful in both but improvements in the second from experience in the first resulted in more satisfactory function. He now eats soft food more or less normally.

The operative procedure was divided into three stages. In the first, through an abdominal approach, the segment of jejunum was isolated and the distal end anastomosed to the stomach. In the second, through the chest, the diaphragm was opened and the proximal blind end of the loop was brought up along with the resected esophagus and out through the neck. In the third the cervical esophagus and jejunum were anastomosed in the neck.

Results so far indicate that the transthoracic route is preferable to the subcutaneous route. Further trial seems warranted.

19. Completing the Multiple-Stage Operation for Atresia of the Esophagus.

Conrad R. Lam, Detroit, Mich.

In a series of 13 infants operated on for congenital atresia of the esophagus with tracheo-esophageal fistula, the preferred operation of direct anastomosis in the mediastinum was carried out ten times. In the remaining three babies, the multiple-stage method was utilized, once from choice and twice from necessity. One of these died immediately after the first stage which consisted of ligation of the fistula followed by a futile attempt to connect the two segments of the esophagus in the mediastinum. The other two children have had the continuity of their alimentary tract established by the construction of an antethoracic esophagus by a method which differs slightly from any previously described.

This experience is presented with the hope that it may be of assistance to surgeons who may be responsible for children who are being fed by gastrostomy for prolonged periods while waiting for the final plastic procedures.

The plan is as follows: If anastomosis is impossible at the time of mediastinal exploration, the detached lower segment is ligated and allowed to retract, and the chest is closed. Two days later, if the condition of the infant warrants, the upper segment is exteriorized in the left clavicular region and is opened to permit sham swallowing. The third stage follows in a few days; it consists of mobilization of the cardiac end of the stomach and lower esophageal segment through an abdominal approach. The latter is exteriorized through a skin tunnel, the end being brought out as high as possible on the chest wall. Feedings through this esophagostomy are carried out during the following year by the intermittent insertion of a catheter. This arrangement presents several advantages over the use of a gastrostomy.

During the second year of life, the two esophagostomies are connected by a skin-lined tube constructed according to previously described methods. The antethoracic tubes in the two children herein reported were completed when they were approximately two years old.

The functional capacity of this type of esophageal reconstruction will be demonstrated by a short motion picture.

Tuesday Afternoon, June 1, 1948

2:00 P.M. Executive Session.

3:00 P.M. Scientific Session.

Address of the President-Alton Ochsner,

New Orleans, La.-factors Influencing Survival

Rate in Primary Pulmonary Malignancy.

20. Decortication in Pulmonary Tuberculosis Including Studies of Respiratory Physiology.

Joseph Gordon, Ray Brook, N. Y.

Edward S. Welles, Saranac Lake, N. Y.

The feasibility of decortication has been demonstrated in a number of instances. The application of this operation to the unexpandible lung which has been under therapeutic collapse for pulmonary tuberculosis poses a number of problems for consideration. The objectives are twofold: 1. The obliteration of the pleural space. 2. The regaining of functional lung. To this end the present study has been undertaken. Patients have been operated upon whose therapeutic pneumothorax has been present from several months to years. The complications present included frank pus containing tubercle bacilli subsequent to previous mixed infection and bronchopleural fistula. The plan of study for these patients included preliminary bronchoscopy and detailed respiratory function measurements before and after the operation.

At the outset it was recognized that because of variable extents of parenchymal disease for which the lungs were collapsed, re-expansion and improved function might not necessarily follow. It was, therefore, considered important to carefully review all previous films, especially those before collapse was instituted, to estimate the maximal extent of visible disease. This would then be a factor in the decision of the advisability of primary decortication or preliminary partial thoracoplasty followed by decortication.

Thus far the material studied indicates, among other things, that empyema is not a deterrent in performing the operations and obtaining primary wound healing. While re-expansion may be anticipated, there are suggestions that this may not be followed necessarily by improved lung functions, but on the contrary by some oxygen desaturation. It is, therefore, of some importance at this stage in our developmental knowledge to have as much detailed information as possible for evaluation of results.

21. Decortication of the Unexpanded Tuberculous Lung Following Pneumothorax.

Joseph A. Weinberg and (by invitation)

J. Dwight Davis, Van Nuys, Calif.

This is a preliminary report on decortication of the unexpanded lung with fluid or empyema development following induced pneumothorax for the treatment of pulmonary tuberculosis. The lung had remained unexpanded and fluid had accumulated eight, nine, eleven and twenty-one months, respectively, prior to decortication in the four cases reported.

Prophylactic streptomycin therapy was given to all of the patients before surgery and was continued for several weeks following surgery.

Observations were carried out for a sufficient time preoperatively to prove that the lung would not re-expand. In one case of frank empyema a positive culture for tubercle bacilli was obtained. Cultures were negative in the three cases of fluid formation without suppuration.

All of the patients were operated upon through an intercostal incision without dividing or resecting a rib. The membrane over the parietal pleura was invariably thicker than the membrane over the visceral pleura. In no instance did the membrane follow the parietal pleura over the hilar region. Instead it was reflected onto the visceral surface at some distance from the hilum, binding the partially compressed lung firmly against the mediastinum.

Evidence of caseating tubercle formation was seen in both the parietal and visceral membranes in two cases. There was one instance with tubercle formation on the visceral surface only, while one case presented no visible evidence of tubercle formation.

Decortication was relatively simple in two cases but was difficult in the two cases showing evidence of more active tuberculous infection.

Excellent expansion of the lung occurred in all four cases following decortication.

The presentation will stress indications for decortication, pathologic changes found at operation and difficulties in technic which one may encounter.

22. Physiological Observations Concerning Decortication of the Lungs.

(By invitation) George W. Wright, Lester B. Yee,

Giles F. Filley Allan Stranahan,

Sunmount and Saranac Lake, N. Y.

One case of chronic tuberculous empyema complicating an inex-pansible lung in the presence of a pneumothorax of four years' duration, and one case of pyogenic empyema of nine weeks' duration complicating a traumatic hemothorax (stab wound), were studied before and after evacuation of the pleural contents and removal of the visceral "peel." The following measurements were made: (1) Maximum Breathing Capacity. (2) Recumbent Lung Volume. (3) Lung Ventilation Efficiency. (4) Bronchospirometry. (5) Arterial Blood Gases at rest and during exercise. (6) Respiratory, Circulatory and Metabolic Responses to Grade Walking on the Motor Driven Treadmill.

In both cases, the collapsed lung was successfully re-expanded and the space obliterated. In the subject having an empyema of short duration, the operation was followed in four weeks by improvement of function, and at the end of seven months, by the restitution of virtually normal function. The postoperative studies of the tuberculous empyema show that at the end of eight months, there has been only a slight increase in the ventilation of the re-expanded lung and no measurable improvement of the respiratory reserves. Moreover, a significant veno-arterial shunt was created in the re-expanded but now poorly ventilated lung as is revealed by the postoperative development of incomplete arterial hemiglobin saturation.

Certain basic concepts of the surgical procedure of decortication as well as fundamental differences in the pathology of the two cases must be considered in explanation of their divergent end results.

23. Allergy of Tuberculosis, With Special Reference to Autotuberculinization.

A. R. Judd, Hamburg, Pa.

This paper presents the problem of allergy or hypersensitivity to tuberculin. The relationship of this hypersensitivity to the sequence of events in a tuberculous infection is discussed. Five cases are presented all of which showed typical symptoms and signs of auto-tuberculinization, including the state of suspended allergy (Mantoux-negative) and X-ray findings considered characteristic of this type of reaction. All of these cases were actually or essentially moribund yet all five cases recovered from their acute episode although one case later died as a result of complications of massive pulmonary hemorrhage. One case showed a dramatic response to the administration of an antihistaminic drug, but it is questioned if this drug (Benadryl) was actually beneficial in combating the allergic inflammatory changes associated with autotuberculinization.

7:00 P.M. Cocktail Party-Chateau Frontenac.

8:00 P.M. Banquet-Chateau Frontenac.