Saturday Morning, May 10, 1952

9:00 A.M. Scientific Session.

21. Silicotc and Tuberculosilicotic Lesions Simulating Bron-chogenic Carcinoma.

Frederick G. Kergin, Toronto, Ont.

The massive densities which sometimes develop in the presence of pulmonary silicosis may be mistaken for a bronchogenic carcinoma; eight such cases have been reported. In only one of these published cases, that of Woodruff and Kelly, was the mass unilateral, and it proved to be a tuberculosilicotic lesion. At the Toronto General Hospital over the past five years seven male patients have been seen who showed on radiographic examination a unilateral density suggestive of bronchogenic carcinoma. All had a history of some exposure to silica although in three patients exposure had been of short duration and had terminated many years ago. In only one patient was there recognizable radiographic evidence of diffuse silicosis.

Six of these patients had symptoms characteristic of bronchogenic carcinoma and were subjected to thoracotomy. In five a pneumonectomy was performed; in the other patient biopsies were taken. Pathological studies showed that in three patients the density was a simple conglomerate lesion of silicosis and in the other three, a tuberculosilicotic lesion.

In the seventh patient without symptoms, the diagnosis of a massive silicotic lesion has been reached on clinical grounds and on the basis of serial roentgenograms, and since he has no disability he has not been treated surgically.

At operation these patients have shown small nodules scattered throughout the lung, which on section were typically silicotic, and in addition there has been a very solid area, segmental in distribution; a characteristic feature has been a very marked degree of fibrosis about the bronchovascular tree with hard fibrotic lymph nodes densely adherent to the bronchi. This characteristic fibrosis, of extreme density, has rendered excisional therapy difficult, and because of it, lobectomy or segmental resection has proved impractical.

The cause of the massive density, in the presence of an underlying silicotic reaction, appears to be chronic obstructive pneumonitis due to fixation of a segmental bronchus, peribronchial fibrosis and partial or complete occlusion from pressure of a hard silicotic lymph node. There is some evidence to suggest that in the patients with tuberculosis, tli2 tuberculous infection was a later invader.

There have been no deaths in this group of patients, and those treated by pneumonectomy have all been relieved of their symptoms.

22. The Elective Resection of Nodular Tuberculosis.

D. O. Shields (by invitation) and John S. Chapman (by invitation),

Dallas, Texas

Data are presented to show that apical nodular tuberculosis is of such a character that its stability can never be certain, and this information is correlated with facts regarding known obturated cavities. The view is taken that in fact multiple nodular tuberculosis is in fact composed of numerous small obturated or inspissated cavities, and that the hazard of spread is equal to or is greater than in the case of the single tuber-culoma. Hence if it is rational to remove single "inspissated or tuberculoma-like cavities", it is certainly rational to elect the resection of multiple nodules, particularly if there has already been evidence of instability. Results of these elective resections are given with follow-up information.

23. The Complications and the Results of Treatment of Bronchopleural Fistula Following Resection for Tuberculosis.

James D. Murphy, Barney B. Becker (by invitation) and

H. V. Swindell (by invitation), Oteen, North Carolina

In spite of the development of chemotherapeutic agents, refinements in surgical technique and improvement in methods of anesthesia, postoperative bronchopleural fistula frequently occurs as a complication of resection for pulmonary tuberculosis. Despite the increased morbidity following development of a fistula, the over-all results of resection have been so favorable as to result in its adoption with increased frequency.

A number of studies have been made concerning the pathogenesis of bronchopleural fistula. Few reports have appeared concerning the subsequent course of this group of patients. If a substantial number of such casualties can be salvaged, resection will be used with more confidence.

This paper deals with the complications we have encountered as a result of bronchopleural fistula in 30 patients. These fistulae developed during a series of 169 resections performed at the Veterans Administration Hospital, Oteen, North Carolina, from October, 1945 to August, 1950. An average follow-up period of 30.5 months has been possible.

The most important complication of a fistula is spread or reactivation of the disease. This occurred in 17 of the 30 patients and caused the death of six patients. Extrapulmonary spread is less common but has proven uniformly fatal when it occurs.

The final results show that 9 of 30 patients who developed a fistula are dead. Eleven remain in the hospital. Ten have been discharged. The fistula has been closed in 16 patients.

Methods of treatment used in this series of patients and the results obtained are considered in detail. As a result of lessons learned with this group, some modifications in treatment have been made during the past year and are presented.

24. Plastic Sponge Prosthesis Following Resection in Pulmonary Tuberculosis.

Joseph W. Gale and Anthony R. Curreri, Madison, Wis.

During the past seven years the authors have been performing an increasing number of resections for pulmonary tuberculosis. Through this period the importance of obliterating the dead space left through lobectomy or pneumonectomy has been recognized. It is well known that a dead space following any surgical procedure is to be avoided if possible. The necessity is still greater in tuberculosis where the disease is more widespread and involves the neighboring lobe or lobes. Over-expansion of the remaining lung tissue will frequently obliterate the dead space, but this occurs at the expense of the remaining tissue. Over-distention and emphysema are not desirable in the presence of tuberculous involvement, and old foci are more apt to reactivate. In the past this situation has been prevented by thoracoplasty at the time of or a few days following the primary resection. Rib resection not only demands a second operation in about 65 per cent of the cases, but adds to the complications with resultant deformity. This is particularly true in growing children.

Grindlay and Waugh, 1951, described the use of a plastic sponge which was very satisfactory when used as a framework for living tissue. In a discussion of this paper one of us felt that its use would be applicable to patients with tuberculosis undergoing resection. We began using this material in April, 1951, and have implanted it in the dead intrapleural space and in the extrapleural space in over 35 cases at the time of and following resection. The results have been most gratifying.

Studies have been made comparing the tissue reaction to the sponge with that to cellophane, cotton, silk, catgut, etc. It now appears that its value is far greater than that of paraffin, lucite balls, and other materials that have previously been used. It is easily sterilized and simple to handle. We are now engaged in getting molds made to duplicate the right and left lungs as well as the individual lobes. If we are successful in this effort, the efficiency and simplicity of the procedure will be greatly increased.

A detailed description of the technique is given, and the advantages and disadvantages, as well as complications, are discussed. Follow-up X-rays are shown.

25. The Role of the Inferior Esophageal Constrictor in the Production of Lower Esophageal Disease.

Earile B. Kay, Cleveland, Ohio

There has been considerable controversy in the past as to the presence or absence of a sphincter-like mechanism at the cardia of the stomach, the esophagogastric junction, or in the lower esophagus. Observations are presented as to the presence of a sphincter-like mechanism in the lower esophagus, referred to as the inferior esophageal constrictor which appears to be a factor in the development of certain lower esophageal diseases such as achalasia, diverticula, and idiopathic strictures. These observations will be illustrated by slides and motion pictures.

26. The Delayed Restoration of Oral Alimentation in Children with an Esophageal Defect Remaining after Closure of a Tracheo-Esophageal Fistula.

N. Logan Leven and Richard L. Varco, St. Paul, Minn.

The successful development, by Leven in 1939, of a surgical technique for saving the newborn with a tracheoesophageal fistula, inevitably posed a reconstructive problem for the future. At our institution 14 of these children have been saved from a hitherto uniformly fatal defect. During this interval an additional 50 tots have had primary restoration of esophageal continuity, as the preferred treatment and when feasible.

In that group cared for by the staged procedure, ten were judged to have grown large enough for the establishment of oral alimentation. Our experiences with this situation, the operative methods used, those limitations recognized in the cosmetic and functional results to date will be considered at some length in the paper. In brief, nine patients have had an antethoracic jejunal loop terminally anastomosed in stages to the residual cervical esophagus and then to the gastric area. The stomach was moved intrathoracically and joined at the superior mediastinal aperture to the gullet in one child. The only youngster to suffer necrosis of the jejunal loop, the tenth case, lost a short segment of the bowel. A sufficient length remained viable, however, that subsequent successful direct union in the usual fashion was carried out. No deaths or fistulae, of more than a few days' duration, have occurred. All patients have returned for follow-up visits at frequent intervals for periods up to about three years.

The weight gains, eating habits, psychological reaction to the operation, and other related items discussed in the paper are based, therefore, on numerous personal interviews by the authors with the parents and the children.