Thursday Morning, March 31, 1949

9:00 A.M. Scientific Session.

21. An Experimental Study of the Blood Supply of the Esophagus and its Relation to Esophageal Resection and Anastomosis.

John Skek, M.D. (by invitation), Carlos Prietta

(by invitation) and E. J. O'Brien, M.D., Detroit, Mich.

The esophagus of dogs was mobilized from the mediastinum and portions were resected. The cut ends were then anastomosed by using interrupted sutures of fine silk in two layers. It was likewise possible to remove the esophagus from behind the aorta and anastomose it in front of the aorta.

These experiments were carried out with much of the blood supply to the esophagus ligated. Still healing occurred regularly.

Injection studies were made of the esophageal blood supply under various conditions, and it becomes evident that the supply is much better than has been generally thought.

22. The Treatment of Short Esophageal Strictures by Resection and End-to-End Anastomosis.

William M. Tuttle, M.D. and J. C. Day, Detroit, Mich.

It has long been thought that end-to-end anastomosis of the esophagus was not a safe or feasible procedure.

Within the past two years six patients, ranging in age from one to seventy years, with short esophageal strictures have been treated by resection of the stricture either completely or by a wedging type of resection and the normal ends reunited by interrupted sutures in two layers.

There has been a good functional result in each patient. In no instance has the anastomosis leaked.

23. Acquired Nonmalignant Esophago - Tracheobronchial Fistulas.

Frank Philip Coleman, M.D., and

George H. Bunch, jr., M.D. (by invitation), Richmond, Va.

Malignant lesions account for the majority of acquired communications between the esophagus and tracheobronchial tree. The nonmalignant fistula may be caused by trauma, tuberculosis, syphilis, esophageal diverticula and pyogenic and fungus infections. Frequently, the underlying pathologic probess cannot be ascertained at the time of operative closure of the fistula. The hopeless prognosis of bronchiogenic and esophageal cancer associated with esophago-tracheobronchial fistulas and the infrequency of acquired non-malignant communications between the esophagus and tracheobronchial tree have resulted in the accumulation of meager experience in managing this distressing complication of trauma and infection. To the seven case reports in the English literature of operative closure of esophago-respiratory fistulas, the authors have added four successful cases. The clinical features, preoperative care, problems of anesthesia, and surgical technic are emphasized. (Motion picture illustrating surgical technic.)

24. The Combined Abdominal and Right Thoracic Approach to Lesions of the Middle and Upper Third of the Esophagus.

Edward M. Kent, M.D. and Samuel P. Harbison

(by invitation), Department of Surgery, Pittsburgh School of

Medicine, Pittsburgh, Pa.

Following Ivor Lewis' lead, a traumatic stricture of the upper two-thirds of the esophagus was successfully treated by resection and esophago-gastrostomy through the right thorax in August 1947. The ease with which the entire esophagus to the top of the thorax may be resected by this approach logically led to the development of the method for malignant disease. The operation is necessarily done in two stages, performed a week apart or at the same time. The abdomen is opened first and exploration carried out. If no metastases are present, the stomach is carefully divested of its entire blood supply save for the right gastric and right gastroepiploic arteries. Dissection is carried to the esophagus itself and an inch or so of this organ is freed up. In markedly debilitated patients who have complete obstruction, a jejunostomy may be established before closing the abdomen.

At the second stage the right thorax is entered posterolaterally by resection of a suitable rib. If operable, the lesion is mobilized widely after ligation of the azygos vein. The stomach is then delivered after enlarging the esophageal hiatus, resection is carried out and an esophagogastrostomy accomplished. The principal advantage of the right approach lies in the absence of the aortic arch on this side; dissection does not have to be performed beneath it; and the resulting anastomosis, whether above or just below the arch, is not angu-lated as is the case on the left. Details and pitfalls of the method are described. It is believed that a better salvage of patients with esophageal malignancies will be obtained by this more direct approach to the lesion.

25. Packing of the Superior Mediastinum in the Treatment of Esophageal Varices Due to Portal Obstruction.

John H. Garlock, M.D. and Max Som, M.D.

(by invitation), New York, N. Y.

The authors submit a supplementary report on the original paper published in the Journal of the American Medical Association for November 8, 1947, at which time they reported two cases accorded this therapy. The idea is based on the supposition that by establishing a large area of granulation tissue external to the muscular layer of the esophagus at a distance removed from the seat of the varices there will develop a collateral circulation which will be outside of the esophagus, thereby taking the load off the venous pressure in the esophageal varices which lie in a submucosal position. On the basis of an experience with ten cases there would seem considerable justification for this procedure before the surgeon should consider the more extensive and more dangerous operation of portocaval shunt or splenorenal vein anastomosis. The authors will report in detail the history of ten patients, the longest follow-up being seven years.

26. Pulmonary Alveolar Adenomatosis.

H. Brodie Stephens, M.D. and Sidney J. Shipmen, M.D.,

San Francisco, Calif.

Pulmonary alveolar adenomatosis, or jagziekte disease, has awakened increasing medical interest as the condition has been recognized in human beings. Long recognized as an endemic disease of sheep it has now been found to affect human beings more and more frequently. Nevertheless, until 1947, only twelve authentic cases were on record, only one of which was diagnosed prior to death, the case of Pierson, Holman and Wood, in which the diagnosis was made at operation.

In the case reported herewith it was possible to make the diagnosis before surgery, to confirm it by lobectomy and to bring about apparent cure.