Monday Afternoon, April 16, 1951

2:00 P.M. Scientific Session.

7. Changes in Urine and Serum Electrolytes and Plasma Volume After Major Intrathoracic Operations.

Robert K. Finley, Jr. (by invitation), John Y. Templeton, III

(by invitation), Robert H. Holland (by invitation) and

John H. Gibbon, Philadelphia, Pa.

Changes in serum electrolyte concentrations and urinary excretion and alterations in the plasma volume are as important after intro-thoracic operations as after major operations elsewhere in the body. In seventeen patients subjected to major thoracic operations studies have been made of the changes in the urinary excretion and serum levels of sodium, potassium and chloride ions and in the plasma volume, hematocrit and thiocyanate space. The blood lost during operation, estimated by weighing the sponges used, was replaced. In most patients total eosinophile counts were made in the pre- and postoperative periods, with observations on the eosinophile response to AGTH.

The usual changes in the eosinophile count were observed, with an immediate postoperative drop and a beginning rise to the pre-operative level between the first and fifth days, the average rise occurring on the fourth postoperative day. Changes in the urinary excretion of sodium and potassium were of longer duration. The urinary excretion of sodium was markedly decreased postoperatively and the urinary excretion of potassium was increased. The urinary sodium did not rise, or the potassium fall, until four to eight days after operation. This change appeared on the average between the sixth and seventh postoperative day. Urinary chloride excretion paralleled urinary sodium excretion in direction, but not quantitatively. The findings indicate longer duration of the measurable effects of 11-des-oxycorticosterone-like steroids than of the 11-oxysteroids.

Changes in the concentration of electrolytes in the serum were variable and not related to the urinary excretion. The plasma volume tended to fall, and the hematocrit to rise, in the immediate postoperative period. An attempt was made to compensate for the decreased plasma volume by administering plasma or a plasma substitute (ossein gelatin). The effects of such maintenance of the plasma volume were thought to be beneficial. However, maintaining a normal plasma volume in the postoperative period did not appear to alter the urinary electrolyte patterns. It is suggested that caution be used in administering electrolytes intravenously in an attempt to restore a normal serum level until urinary electrolyte excretion has returned to normal.

8. The Treatment of Cardiospasm: Analysis of a Twelve-Year Experience.

Arthur M. Olsen (by invitation), Stuart W. Harrington,

Herman J. Moersch and Howard A. Andersen

(by invitation) Rochester, Minn.

This paper is concerned with the results of treatment of 609 patients with cardiospasm who were seen at the Mayo Clinic between January 1, 1935 and January 1, 1947. In all of these patients, dilatation of the cardia was carried out. The dilatations were performed over a previously swallowed thread, and in the great majority of instances the cardia was forcefully dilated with the Plummer hydrostatic dilator. The evaluation of this method of treatment is based on follow-up observations extending from four to sixteen years. A detailed analysis of our results will be presented. In general, it may be stated that the majority of our patients have obtained satisfactory and lasting relief of dysphagia from the dilatations we have performed.

Seventeen patients were treated by various surgical procedures. The methods of surgical approach will be evaluated, especially with respect to late results. There are definite indications for the surgical treatment of cardiospasm, but the surgical methods often have their limitations.

In the course of this study a great deal of information has been accumulated which concerns the incidence, etiology, symptomatology, diagnosis and complications of this disease. This material will be considered in other communications, but certain pertinent facts will necessarily be included in this paper. Careful roentgenologic examination and endoscopic technics are necessary for accurate diagnosis. The evaluation of the therapy of cardiospasm requires that this condition be differentiated from diffuse spasm of the esophagus and other lesions of the lower part of the esophagus.

9. Consideration as to Etiology and Treatment of Achalasia of the Esophagus.

Earle B. Kay, Cleveland, Ohio

Numerous theories have been evolved as to the etiology of achalasia for the esophagus most of which are obviously unproven. Certain observations have presented themselves to the author during the conservative and operative treatment of these patients which are felt to have some bearing on the etiology of this condition. Additional studies have been made in behalf of these observations which will be presented.

The observations as to etiology are also reflected in the types of therapy provided. The advantages and disadvantages as well as the complications of various types of surgical therapy are discussed in considerable detail, particularly the complication of postoperative regurgitant esophagitis and ulceration as seen in some patients following the Heineke-Mikulicz and Finney cardioplasty.

10. Complications and Surgical Treatment of Hiatus Hernia and Short Esophagus.

Donald B. Effler, Cleveland, Ohio

A brief classification of hiatus hernia is presented. The thoracic stomach associated with short esophagus is differentiated from the para-esophageal or "pulsion" hiatus hernia.

A series of thirty-three cases of complicated hiatus hernia are presented. The complications are discussed and classified under (1) Bleeding manifestation; (2) Peptic ulcer; (3) Obstructive phenomena associated with incarceration or volvulus.

One method of transthoracic surgical repair is described. Emphasis is placed on the postoperative care and follow-up observation. There have been no operative mortalities and the morbidity has been gratifyingly low. Surgical correction has brought almost immediate relief of symptoms attributable to the hernias.

The complications of short esophagus with thoracic stomach are presented. Ten proven cases of short esophagus are reported and the surgical procedures described.

11. Formation of a Temporary External Esophageal Fistula Over a T-Tube for Stenosing Esophagitis.

Philip Thorek (by invitation), Chicago, Ill.

A case of stenosing esophagitis is herein reported which resulted in almost complete obstruction of the lower end of the esophagus, and was associated with encapsulated fluid in the lower left chest (probably due to esophageal spillage).

Resection was considered impossible because of the patient's condition, the contaminated pleural cavity and the condition of the esophageal wall.

A temporary external esophageal fistula over a T-tube was created.

Bilateral vagotomy to diminish hypersecretion and hyperacidity was done.

The patient's condition continues to improve, the fistula is closed and the dysphagia has not recurred.

In a review of the literature no report could be found of a procedure of this type being done for stenosing esophagitis.

12. Endoscopic Sponge Biopsy.

Max G. Carter (by invitation), Clinton A. Piper

(by invitation) and Robert Nesbitt (by invitation)

New Haven, Conn.

The sponge biopsy technic has been applied in a series of seventy-five patients subjected to diagnostic bronchoscopy or esophagoscopy. The diseases studied included lung abscess, bronchiectasis, bronchial adenoma, bronchiogenic carcinoma, pulmonary emphysema and both carcinoma and benign stricture of the esophagus. The series of tumors was not large enough for significant statistical interpretation but diagnostic accuracy was high and there were no false positive reports.

"Onkasponge" biopsy proved superior to the Papanicolaou smear technic previously used by us. There were fewer inadequate specimens, preparation and staining of the sections were much simpler and accurate interpretation of the slides was easier. Greater diagnostic accuracy may be expected from the pathologist when using this method since the interpretation of "onkasponge" slides is comparable to that of tissue sections.

The technic of "onkasponge" biopsy is described and illustrative photomicrographs are presented.