Monday Morning, May 7, 1956

8:30 A.M. Business Meeting.

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

1. Congenital Diaphragmatic Hernia and Hypoplastic Lung: A Clinical Evaluation.

Benson B. Roe, San Francisco, Calif.

Congenital diaphragmatic defect through the foramen of Bochdalek is described as a surgically correctible lesion with encouraging results and low mortality. The author has gathered and analyzed 43 cases with an overall mortality rate of 60.5%, suggesting that the total experience is far from satisfactory. A large proportion of the cases diagnosed immediately after birth did not survive long enough to reach surgery; the operative mortality in the others was exceedingly high (66%). In sharp contrast were the excellent surgical results in the group operated at three weeks or more of age (8%), many cases having survived without significant pulmonary or gastrointestinal embarrassment for periods of months to years. These groups are not separated in most of the published series and emphasis is placed on so doing for more honest evaluation of surgical indications and results in the neonatal period.

Evidence is presented to suggest that these patients fall into separate categories on the basis or possessing at birth adequate or inadequate pulmonary parenchyma to support life. Analysis of the autopsied cases reveals a very high incidence of hypoplastic lung-not only on the hernia side where vestigial unexpandable lungs are common but also in terms of significantly subnormal total lung weights.

On the basis of this information the problem will be reassessed as to the optimal operating time and post-operative management of the unexpanded hypoplastic lung.

2. Critically Crushed Chests: A New Method of Treatment by Internal "Pneumatic" Stabilization with Continuous Mechanical Hyperventilation.

Edward E. Avery (by invitation), E. Thier Mörch (by invitation)

and Donald W. Benson (by invitation), Chicago, Ill.

A new method of stabilizing the flail thorax is presented. Hyperventilation is used by means of a specially designed respirator delivering a fixed volume of gases for intermittent positive pressure endotracheal ventilation.

Methods of external stabilization frequently fail to provide adequate air exchange because of the patient's inability to consciously ventilate himself due to extensive bond, muscle, nerve and brain damage. Mechanical ventilation has not been effectively applied in the past because of improperly designed apparatus, mechanical breakdowns, sticking valves, fluctuating stroke volumes, etc.

A deterrent to the application of prolonged passive (mechanical) hyperventilation has been the time honored fear of the adverse effects of the active hyperventilation syndrome as seen in hysteria, volunteers, and metabolic acidosis. None of these ill effects has been seen with continuous passive hyperventilation continued for periods of more than a month. Another deterrent to this new method of treating crushed chests has been the numerous references in the literature regarding deleterious response of the circulation to intermittent positive pressure insufflation. The circulation in our patients has not been disturbed when the pressure variations within the trachea have the correct amplitude and time profile.

Experimental studies on animals and the clinical application of mechanical hyperventilation to patients with crushing injuries of the chest are presented with slide and movie illustrations.

3. Complete Traumatic Rupture of the Left Main Bronchus Successfully Repaired Eleven Years After Injury.

Daniel E. Mahaffey (by invitation), Oscar Creech, Jr., Hollis G. Boren

(by invitation) and Michael E. DeBakey, Houston, Texas

This is a case report dealing with an adult male who sustained a crushing injury of the chest in 1944 while on active duty with the Navy. Following hospitalization he was discharged from the service with a diagnosis of atelectasis of the left lung.

Upon admission to the hospital in 1955, a diagnosis of traumatic rupture of the left main bronchus with complete occlusion was made and confirmed by bronchoscopy, bronchography and pulmonary function studies. At operation the involved segment of bronchus was excised, bronchial continuity restored and the left lung re-expanded. Serial differential bronchospirometric determinations have been performed to determine the evolution of pulmonary function since operation. This appears to be the first late case of traumatic bronchial rupture studied in this way. A brief motion picture will be shown to demonstrate the operative technic.

4. Congenital Atresia of Esophagus.

George H. Humphreys, Bruce M. Hogg (by invitation) and

Jose Ferrer (by invitation), New York, N. Y.

This report reviews the results of treatment of 136 infants with congenital esophageal atresia with or without fistula, seen at Babies Hospital or born in Sloane Hospital in the half century between 1903 and 1953. The history of the evolution of diagnosis and treatment is briefly reviewed. This parallels the experience in other clinics and brings out the lag between the first clinical and pathological description two centuries earlier, the first accurate clinical diagnosis in 1923, and the first patient to survive operative correction in 1942. The increasing frequence of admission of correctly diagnosed infants in subsequent years is thought to indicate that the incidence is not as low as formerly thought. In this group it is about one in 3,000 births.

Factors influencing survival are shown to be the size and degree of prematurity of the infants; the presence of other severe malformations; the awareness of doctors and nurses caring for newborn infants of the possibility of the condition and their alertness in recognizing the characteristic symptoms; the promptness with which such patients are referred for operation; the care in pre and post-operative management; and the technical aspects of the operation itself. The first two factors are uncontrollable; the others can be better controlled than is often the case. While occasional cases will present anomalies requiring multiple procedures, in the majority swallowing can be restored by end-to-end anastomosis of the esophagus. Results of every procedure are analyzed.

5. Torek Esophagectomy: "The Case Against Segmental Resection for Esophageal Cancer".

William L. Watson, John T. Goodner (by invitation), Theodore

P. Miller (by invitation) and George T. Pack (by invitation),

New York, N. Y.

Longitudinal spread of esophageal cancer by way of the submucosal lymphatics occurs in a high percentage of cases and leads to tumor outcroppings, sometimes three or more centimeters distant from the palpable and visual limits of the primary cancer. Recognizing this feature of the disease as a common cause of our failure to cure we have again resorted to the subtotal (Torek) type of esophagectomy for cancers located in the upper two-thirds of the esophagus.

Forty-eight patients have been subjected to a Torek type of esophagectomy and in 31 cases the swallowing function has been re-established in one of a number of different manners. The major objection to the Torek procedure has been the postoperative problem of restoring adequate continuity between the hypopharynx and the gastrointestinal tract. We have attempted reconstruction of alimentary continuity by a number of different methods.

Although our experience so far has been limited to 6 cases, we are of the present opinion that for cancer of the upper two-thirds of the esophagus a subtotal esophageal resection is our most successful cancer operation and the right colon substernal transplant reconstruction is our most satisfactory procedure.

6. Cardiac Surgery with Hypothermia and Acetyl Choline Arrest.

Peter V. Moulder (by invitation), Richard Thompson (by invitation),

Curtis Smith (by invitation) and William E. Adams, Chicago, Ill.

Hypothermia per se has been found to have little deleterious effect upon the heart when a relatively normal acid-base relationship is maintained. This has been monitored with the use of a constant recording carbon dioxide meter sampling the intratracheal tube. It has been found that low volume respirations at the rate of only 3 per minute are needed to maintain normalcy at 22-25° C. The hypothermia under these circumstances has been found to protect the heart considerably, but when total circulatory arrest is produced, this is incomplete. Arrest or profound slowing of the heart adds further needed protection. Intracoronary acetyl choline produces a profound slowing of the heart during occlusion and its effect can be routinely reversed with the use of intra-coronary atropine.

The following operative procedures have been performed on 43 dogs using this method of preparation: 1. Circulatory arrest alone; 2. Right atriotomy with or without formation and closure of septal defects; 3. Right ventriculotomy with or without formation and closure of septal defects; 4. Left atriotomy with direct procedures on the mitral valve; 5. Occlusion of the coronaries, opening of aorta and direct procedures on the aortic valve; 6. Direct incision and suturing of the coronary arteries.

At the present time only right atriotomy with repair of interatrial septal defects has been successfully performed in humans with this method, and it appears to be as promisingly useful as it has been in dogs.