Wednesday Afternoon, April 18, 1951

2:00 P.M. Scientific Session.

28. Reconstructive Surgery of the Trachea and Bronchi: Late Results With Dermal Grafts.

Paul W. Gebauer, Honolulu, Hawaii

This paper summarizes the late results of dermal grafts used for the relief of severe strictures of the trachea and bronchi. Of fifteen patients operated upon, dermal grafts were used in thirteen. One of these, a tracheal graft, died; two are less than one year postoperative, and ten are from 22 to 31 months postoperative. A functionally adequate tracheobronchial lumen, and relief from obstructive symptoms have been gained in each instance. In some patients the anatomic result has been practically faultless. The only deaths resulted from efforts to relieve asphyxiating tracheal stenosis. There have been no deaths in the bronchial graft series, no serious early complications, and no late complications which have not responded to treatment. Pulmonary resection subsequent to grafting has been performed only once, when clearing of an atelectasis consequent to the reopening of a bronchus, revealed bronchiectasis. The gross and histologic findings in this graft, which had been in situ almost one year, exceeded all expectations and have been reported. In the remaining patients pulmonary resection was obviated, or its extent diminished by the reconstruction of the main bronchial stenosis. Thoracoplasty has been performed on one patient, seven months after bronchial graft, for recurrent tuberculous infiltration in the residual lower lobe, without any complication.

Bronchoscopic epithelial biopsies of dermal grafts taken from five weeks to over two years after operation are reported.

The cases summarized in this paper represent a small segment of a large group of patients with tracheobronchial tuberculosis in whom clinical and pathologic studies have been done. These studies form a basis for an appraisal of the pathogenesis of bronchostenosis, its treatment, and related experimental studies which have been published.

A kodachrome movie (8 minutes) of an operation showing the preparation and insertion of a tracheobronchial dermal graft, and right upper lobectomy is presented.

29. Myxochondroma of the Trachea: A Case Report.

Byron H. Evans, Los Angeles, Calif.

A case is presented of the surgical management of an obstructing lesion of the upper trachea. The patient, a 59 year old man, had noted the presence of a tracheal wheeze for one year which had gradually become more severe with productive cough and dyspnea. The tumor was removed by direct surgical excision through the neck after a preliminary low tracheotomy had been done. The tracheal defect measuring 3 x 1.5 centimeters was then successfully repaired by the utilization of a full thickness skin graft taken from the inner aspect of the upper arm, reinforced by lacing with #28 stainless steel wire after the method of Gebauer. Recovery was uneventful with restoration of a normal contour to the trachea on x-ray examination and the preservation of an adequate speaking voice. The lesion proved to be a myxochondroma arising from the first tracheal cartilage.

30. Analysis of Twenty-four Cases of Acute Cardiac Arrest.

J. L. Ehrenhaft, D. W. Eastwood (by invitation) and

L. E. Morris (by invitation) Iowa City, Iowa

Analysis of twenty-four cases of cardiac arrest occurring during anesthesia for various types of surgical procedures is presented. About half of this number received treatment which is believed to be adequate. The remainder were subjected to artificial circulation by varied approaches with varied lengths of survival. As a result of this study it has been found that hypoxia was the usual precipitating cause of the acute cardiac arrest. Early recognition and immediate institution of artificial circulation and adequate artificial ventilation are the most important steps in the resuscitation of the patients.

It has been shown in dog experiments that after producing acute cardiac arrest it is possible to restore normal cardiac action and' that during the period of artificial circulation adequate arterial oxygen saturation can be maintained.

31. Gonstrictive Pericarditis and Gonstrictive Pleuritis Treated by Pericardectomy and Pulmonary Decortication.

Richard H. Overholt, C. Sidney Burwell (by invitation),

John W. Woodbury (by invitation) and James H. Walker

(by invitation), Boston, Mass.

Combined constrictive pericarditis and constrictive pleuritis may be produced by either infection or trauma. A case is presented representing the sequelae of a crushing injury to the chest. Attention is drawn to the necessity of resecting the constricting membranes both from the heart and the lungs if the maximum rehabilitation is to be accomplished. A transpleural approach through a left posterolateral incision affords ample exposure for resecting the constricting membranes from the left heart, right ventricle and the left lung. Cardiac catheterization data and ventilatory function studies were obtained before and after operation, and these demonstrated improvement in both the circulatory and pulmonary dynamics.

32. The Direct (Brock) Relief of Pulmonary Stenosis in Tetralogy of Fallot.

Robert P. Glover, Charles P. Bailey and

Thomas J. E. O'Neill (by invitation), Philadelphia, Pa.

This report is based upon twenty-three cases of Tetralogy of Fallot in which the Brock procedure or some modification was employed to overcome the pulmonary obstruction. In this group there were eight cases of valvular stenosis, six cases of arterial stenosis, and nine cases of infundibular stenosis. The exact pathology of infundibular stenosis is still subject to some dispute, and we are presenting the different types of such pathology which we have observed.

There were six deaths in this series, two of them occurring in deeply cyanotic infants under four months of age. In seven cases the cardiac contractions ceased before the heart was approached or manipulated. Notwithstanding, this relief of the obstruction was immediately undertaken and successfully accomplished in three cases.

It will be appreciated that during the course of operation in certain cases cardiac standstill will occur before an anastomotic procedure can be successfully completed, and so the mortality might be charged to the exploration alone. The approach used in the Brock procedure, however, lends itself readily to prompt relief of the pulmonic stenosis in most cases while at the same time it affords exposure of the heart necessary to resuscitation. Therefore, out of the total number of cases in which anesthesia is administered or a thoracotomy is performed the mortality arising from the Brock technic should be lower.

The results in our surviving patients have been gratifying in that the arterial oxygen level has approached a satisfactory saturation and work capacity of the individual is greater than that obtained in most of our observed cases of systemic-pulmonary anastomoses. Theoretical considerations would be in agreement with these observations because there is a reduction in the number of heart defects by this method whereas there is an increase in the number of defects in using the anastomosis procedures.

The anastomotic procedures have heretofore been highly successful in many instances and it is not our implication that they should be entirely discarded. There are many individuals who cannot be helped by the direct approach, especially those with atresia of the pulmonary artery or right ventricular outflow tract as well as cases with tricuspid atresia and so their improvement will be dependent upon successful application of the vascular shunt operations.

33. Treatment of Coronary Artery Insufficiency by Implantation of the Internal Mammary Artery Into the Left Ventricular Myocardium.

Arthur Vineberg, Montreal, Canada

Many attempts have been made to augment the circulation of the ventricular myocardium in cases of coronary artery sclerosis. In the past there have been four main approaches to the problem, namely application of a vascular graft to the surface of the heart; cardiopericardiopexy; cardiac vein ligation; arterialization of the coronary venous system.

A different approach to the vascularization of the ventricular myocardium was first attempted by us in 1945. The left internal mammary artery was employed as a source of fresh arterial blood for the ventricular myocardium. The internal mammary artery was transected and detached from its chest wall bed. It was then placed within a tunnel in the ventricular myocardium. An anastomosis developed between the implanted internal mammary artery and the left coronary circulation. The presence of the anastomosis was proven by injection studies, radiographs, plastic casts and serial sections.

Anastomosis occurred in from 50 to 75% of the animals, dependent on the technic of implantation use. The value of an internal mammary-coronary anastomosis in animals was studied. This was gauged by the mortality rate and the appearance of ventricular infarct after ligation of the anterior descending branch of the left coronary artery. The mortality rate and the development of infarcts in such animals were dependent upon the size of the internal mammary coronary anastomosis. In no single case has an animal died or developed infarction following anterior descending branch ligation when a large anastomosis existed in a series of twenty-six animals.

In a control group without internal mammary implantation death occurred in 90% and a 5 x 5 centimeter infarction developed in the surviving 10%.

Glenn and associates have confirmed the occurrence of an internal mammary coronary anastomosis, however, they have suggested that the anastomosis is composed of granulation tissue and tends to disappear at the end of eight weeks. We have shown that the internal mammary artery sends out branches of arteriolar size which have been found to persist fifty-eight weeks after the implantation.

Experimental coronary insufficiency has been developed in dogs by wrapping a sclerosing type of cellophane around the origin of the anterior descending branch of the left coronary artery. Exercise tolerance was determined before and after operation. Four months after cellophane wrapping the exercise tolerance was reduced from an average of seven minutes to one and eight-tenths minutes. Four months after implantation of an internal mammary artery into the ventricular myocardium exercise tolerance of these animals returned to seven minutes.

Three cases of human coronary artery sclerosis with angina pectoris have been operated upon. The last two patients are doing well. A detailed report of these cases with indications for surgery will be given. A colored moving picture demonstrating details of the operative procedure will be shown.