Tuesday Morning, April 18, 1950

9:00 A.M. Scientific Session

20. Congenital Atresia of the Esophagus With or Without Tracheoesophageal Fistula.

Willis J. Potts, M.D., Chicago, Ill.

This paper is based on a study of 33 cases.

End-to-end anastomosis of the esophagus was possible in all 29 patients who had type III deformity.

Subperiosteal resection of a long segment of the third or fourth rib posteriorly gives better exposure and is less apt to be associated with a break in the pleura than resection of short segments of a number of ribs. The technic of operation is simplified by the use of special fine-toothed clamps.

High mortality rates persist because of late diagnosis, prematurity, early pneumonia and/or atelectasis and multiple associated congenital anomalies.

Thirteen patients survived surgery.

A case of atresia of the esophagus (type I) is reviewed and illustrated in detail. At the primary operation the ends of the esophagus could not be apposed. Later a gastrostomy was done and the upper end of the esophagus brought out at the neck. At one year of age the stomach was freed and successfully anastomosed antethoracically to the upper end of the esophagus. At age two years, because the subcutaneous stomach became very large, it was moved into the chest by cutting all the ribs anteriorly on the left side at the sterno-costal junction and splitting the diaphragm.

The child survived and is doing well.

21. Reconstruction of Esophagus.

Ross Robertson, M.D. and S. T. R. Sarjeant, M.D.

(by invitation), Vancouver, B. G.

A new method of reconstruction of the entire esophagus in one stage is described. A tube of jejunum is prepared by the method of Roux or Reinhoff and brought up into the neck through the anterior mediastinum. The pleura is not opened and shock is minimal.

The procedure is particularly useful for lye strictures or congenital defects, requiring reconstruction of the entire thoracic esophagus. It is also valuable as a stage procedure for carcinoma of the esophagus, where the operative risk is great or the stomach must be sacrificed.

Five patients have been operated on, with two deaths and three successes. The deaths occurred in the first two patients in the series and were the result of complications which were avoided in the succeeding cases by changes in operative technic and postoperative care.

22. Use of the Burns' Valve as a Simple Respirator for Intrathoracic Surgery in the Dog.

Joseph T. Dameron, M.D. and David G. Greene, M.D.

(by invitation), Buffalo, N. Y.

The efforts of members of the Surgical Staff at this hospital were greatly handicapped by the utter lack of a simple respirator which did not produce anoxia and a progressive increase in CO₂ content of the blood when attempting various intrathoracic operations in the dog. The Burns' Valve (1) was developed during the last war for the Air Force as a respirator for the crew and pilots. This report concerns itself with adaptation of this valve for intrathoracic surgery in the dog. The advantages of the valve are:

(1) It operates from a tank of compressed air or oxygen requiring no electric motors or gears, which are explosive hazards.

(2) The lungs may be distended rhythmically, to any predetermined pressure.

(3) The cardiac output is not decreased significantly.

(4) Anoxia does not develop if the valve is operated from a tank of compressed air.

(5) The blood CO₂ decreases instead of rising to abnormal limits.

(6) A trained individual is not required to operate the device.

(7) It is inexpensive and simple to operate.

The animal is usually anesthetized with pentothal anesthesia. An intratracheal tube with an inflatable cuff is inserted, and an ether bottle is interposed between the valve and the intratracheal tube. The valve is connected to a tank of compressed oxygen or air. If the valve is set to inflate the lungs to a pressure of 14 cm. of water, the lungs will rhythmically inflate to the desired pressure and supplementary ether may be given as needed.

Over one hundred dogs have been operated upon using this simple and reliable method of anesthesia and respiration.

Measurements of the blood CO₂ tension and O₂ tension have been made during prolonged intrathoracic operations in several dogs and are reported. The CO₂ tension has shown a consistent decrease and the O₂ level has remained at a satisfactory level when compressed air was used to inflate the lungs. When compressed oxygen was employed, the blood O₂ tension has been higher than normal.

We believe that this simple method of rhythmical distension of the lung probably has clinical value.

23. The Development of, and Certain Clinical Applications for a Portable Mass Spectrometer.

Fletcher A. Miller, M.D., A. O. C. Nier, M.D.,

Allan Hemingway, M.D., Ralph T. Knight, M.D. and

E. B. Brown, M.D. (by invitation) and Richard L. Varco, M.D.

Minneapolis, Minn.

Considerable interest has recently evolved concerning the development of hypercapnia with its associated acid-base disturbance during anesthesia. There has been extensive speculation regarding the ill effects of this imbalance, but the absence of an efficient means for the analysis of carbon dioxide in the presence of anesthetic gases has hampered work in this field. An early recognition and evaluation of hypercapnia during surgery has therefore been difficult.

Dr. A. O. C. Nier, with the aid of graduate assistants, has recently designed and constructed a portable mass spectrometer capable of continuous analysis of five different gases every 20 seconds with an accuracy of approximately one percent. This electronic device serves a dual purpose at the University of Minnesota Hospitals. First, it has been used in the laboratory of respiratory physiology for pre- and postoperative evaluation of pulmonary efficiency by means of lung volume determinations and other specific tests designed to quantitate the efficiency of alveolar ventilation. Secondly, in the operating rooms, continuous analyses of exhaled air, carbon dioxide and a variety of anesthetic gases have been obtained. These data have been checked against arterial blood pH determinations. The results and clinical correlations will be reviewed.

24. The Surgical Treatment of Giant Emphysematous Blebs and Pulmonary Tension Cysts.

David J. Dugan, M.D. and Paul C. Samson, M.D.

Oakland, Calif.

Definitive therapy in the management of the individual with bullous emphysema has long been a challenge. Medical treatment to date has not been effective.

The results obtained in a series of cases treated by pulmonary resection have been encouraging. The cases subjected to surgery have been carefully selected. The importance of painstaking evaluation of the individual surgical candidate cannot be overemphasized. As is true in all types of operative procedures, the best results are obtained in the younger age group, although such fact does not preclude surgery in the older individuals if legitimate indications exist. The extremes in our cases were three months and sixty years of age.

In the past three years, we have operated on 14 patients with bullous emphysema and cystic disease with accompanying emphysema by either lobectomy, segmental resection or wedge resection of the tissue involved. While the long term results are not as yet available the preliminary results have been gratifying.

The history, course and findings of the 14 cases are presented in detail together with the criteria used for selection of operative cases. The various theories regarding etiology are discussed and the gross and microscopic pathology of emphysema is presented.

25. Experimental Tuberculosis. Effects of Ligation of Pulmonary Arteries on Tuberculosis in Monkeys.

H. William Scott, Jr., M.D. (by invitation)

C. Rollins Hanlon, M.D., Baltimore, Md., and

Byron J. Olson, M.D. (by invitation), Bethesda, Md.

For many years there have been sporadic attempts to modify the course of human pulmonary tuberculosis by ligation of a pulmonary artery. These clinical efforts have been few in number and results are difficult to assess from available reports. We have undertaken a study of the effects obtained by ligation of pulmonary arteries in experimental tuberculosis. Monkeys have been given a standard dose of human tubercle bacilli by intravenous injection. In some of these animals the right or left main pulmonary artery has been ligated. In others only an upper lobe branch has been interrupted. These ligations have been carried out both before and after the injection of tubercle bacilli. A comparable number of unoperated monkeys have served as controls. Results will be discussed and illustrated by colored slides of autopsy material.