Sunday Morning, April 24, 1955

8:30 A.M. Business Meeting.

9:00 A.M. Scientific Session: REGULAR PROGRAM.

1. Pleurobiliary and Bronchobiliary Fistulae.

Herbert D. Adams, Boston, Mass.

Pleurobiliary fistulae are not rare among thoracic war casualties and usually respond well to prolonged suction drainage. Among civilian patients, however, pleurobiliary and bronchobiliary fistulae are very rare but when they occur a serious and complex surgical problem is presented.

Any obstruction of the biliary tract that causes the accumulation of bile beneath the right diaphragm plus secondary infection may erode through the diaphragm. If the pleura is free, a pleurobiliary fistula is established. The symptoms are those of a massive effusion. Bile is obtained on thoracentesis, with subsequent rapid re-accumulation. The treatment is closed pleural drainage and administration of the proper antibiotic. When the patient's condition permits, the pathologic condition in the biliary tract must be treated surgically.

If at the time of rupture through the diaphragm, the pleura is fused, there will be rapid perforation into a bronchus, producing a bronchobiliary fistula and profuse "biliptysis". The surgical management of bronchobiliary fistula requires first, the appropriate surgical procedure to relieve the biliary obstruction which is the basic cause of the fistula. When this is accomplished, the fistula will close spontaneously in some cases. In other cases in which the biliptysis persists, a lobectomy will be necessary to cure the patient. Two cases to illustrate each of these conditions are presented to show the etiology, clinical course and surgical management of these /unusual conditions.

2. Staphylococcal Pneumonia in Infants: A Report of Ten Cases.

W. E. Bloomer (by invitation), R. E. Cooke (by invitation), G. E. Lindskog,

and S. Giammona (by invitation), New Haven, Conn.

Staphylococcal pneumonia represents a special type of pneumonia in that (1) the majority of cases occur in infants, (2) it is associated with empyema in a high percentage of cases, (3) pneumatocele as a residual is not uncommon, (4) there is a high incidence of complicating bronchopleural fistula often with a rapidly developing tension pneumothorax, (5) mortality without proper treatment is very high. It, therefore, may represent a very serious emergency.

In general the causative organism can be recovered from nasopharyngeal cultures and always from the pleural fluid when an effusion develops. The staphylococcus recovered in these cases is generally found resistant to the more commonly used antibiotics, particularly penicillin and streptomycin.

After admission of a case with a presumptive diagnosis of Staphylococcal pneumonia, equipment for an emergency thoracentesis should be kept available in the patient's room so as to handle a tension pneumothorax without delay when this emergency arises. Three of the ten cases presented the emergency picture of a tension pneumothorax.

Experience with ten cases, all of whom were less than four months of age and seven of whom had empyema, suggests that routine use of antibiotics and simple thoracentesis is not the ideal treatment. The early introduction of adequate polyethylene catheter suction and the use of appropriate antibiotics constitute the basis of management. There have been no deaths in this series.

3. Management of Massive Hemoptysis, Not Due to Pulmonary Tuberculosis or Neoplasm.

J. L. Ehrenhaft and Rodman E. Taber (by invitation), Iowa City, Iowa

Rarely patients are seen with massive life-threatening hemoptysis, the reason for which is obviously neither tuberculosis nor neoplastic disease. We have seen eight patients in the last five years who fall into this category. Occasionally these patients had episodes of previous bleeding of less severe degree. The history and routine roentgenologic studies have usually not indicated the site or cause of bleeding. The handling of these patients prior to emergency thoracotomy will be discussed. It has usually been possible to perform segmental resection or lobectomy to eradicate the bleeding sites. The most important diagnostic procedure in our opinion is bronchoscopy during or immediately following bleeding episodes.

The pathologic examination of the resected specimens has been rather disappointing even though attempts to demonstrate the bleeding points have been made by injecting plastic material into the bronchial and pulmonary arterial tree. Early resection of the bleeding area as soon as the site is located is indicated in our opinion. Delay of surgery or procrastination of definitive treatment may result in exsanguination or fatal asphyxia due to aspiration of blood. Illustrated case reports will be presented.

4. The Significance of the Anterior Segment in Bronchiectasis.

Richard H. Overholt and Wilford B. Neptune (by invitation),

Boston, Mass.

The surgical spotlight is not often focused upon the anterior segment. In tuberculosis, this area is the least ‘frequent of the upper-lobe segments to become involved. In bronchiectasis, segments in the basal or mid-position have attracted most attention because they are the chief offenders. With the finding of obvious disease below, many surgeons have been content with incomplete bronchographic patterns insofar as upper lobes are concerned. In our experience, however, at least 8 per cent of bronchiectatics have anterior segmental diseases. In a few ill patients, this is the only segment involved.

Escape from detection contributes to surgical failure or half cures. Clockwise rotation of the anterior segment brings it into a dependent position after basal-segmental and middle-lobe resection. Minimal, pre-existing abnormality is then likely to become a process of pathologic significance.

Technically, the right or left anterior segment can be removed individually or in combination with adjoining segments about as easily as any of the other 16 segments. When an anterior segment or a subsegment of it and the middle lobe are involved (the most common combination), the minor fissure, if present, is usually fused by the inflammatory reaction. Both lobe and segment can be enucleated together with greater facility and safety than with resection of the middle lobe alone.

Cases will be presented to illustrate the significance of anterior segmental disease; in particular, the consequences of oversight during the initial surgical procedure.

5. "Spontaneous" Rupture of the Esophagus.

George W. B. Starkey (by invitation), Boston, Mass.

This paper reports four cases of so-called "spontaneous" rupture of the lower esophagus. All were treated surgically, with three recoveries and one late death. This paper emphasizes once again the relative ease of diagnosis and the necessity for early treatment. In each of the four cases, the initial diagnoses were incorrect; therefore, there was some delay in initiating treatment.

Two of the patients were treated by surgical closure of the rent in the lower third of the esophagus and drainage of the left pleural space. The third patient was treated by thoracotomy drainage only and recovered. The fourth patient, a 69-year-old man, was discovered about seven days after the initial rupture. At this time a left empyema was drained after demonstration of the perforation in the esophagus by routine barium swallow. This patient was recovering but died in his third week after thoracotomy drainage, of a perforated duodenal ulcer associated with hemorrhage from a vessel in the floor of the ulcer.

Emphasis will be laid on the early signs and symptoms, as well as the diagnostic procedures used when ruptured esophagus is suspected. A brief discussion of the literature will precede the presentation of the four cases.

6. One-Stage Pharyngo-Esophageal Diverticulectomy.

J. D. Mortensen (by invitation), O. Theron Clagett,

Herbert W. Schmidt and Howard K. Gray, Rochester Minn.

For more than 40 years surgeons have debated the relative merits and disadvantages of the one-stage versus the two-stage operation for excision of a pharyngo-esophageal diverticulum, and still there is no unanimity of opinion as to the procedure of choice. The most recent and authoritative report is that of Lahey, who strongly defended the two-stage operation and challenged advocates of the one-stage procedure to demonstrate comparable results.

We have reviewed all our cases in which one-stage pharyngo-esophageal diver-ticulectomy was performed during the 10-year period January 1, 1944, through December 31, 1953; there were no cases in which two-stage diverticulectomy was done during this period. The series consists of 339 such cases. Three patients died during hospitalization, giving a hospital mortality rate of 0.9 per cent.

There is no reason to believe that the end results following the one-stage operation should be appreciably superior to those following the two-stage operation, or that the reverse should obtain. From our study of a large group of cases in which one-stage pharyngo-esophageal diverticulectomy was performed we are able to report operative mortality and morbidity rates that are as good as, and in some instances better than, the rates reported for the two-stage operation. Furhermore, the period of hospitalization and the period of observation after leaving the hospital were significantly less following the one-stage procedure. When these economic features are considered together with the emotional benefit to be derived by imposing only one operation, we believe that the one-stage operation for excision of a pharyngo-esophageal diverticulum is preferable to the two-stage procedure.