Tuesday Morning, May 7, 1957

9:00 A.M. Scientific Session: REGULAR PROGRAM-Grand Ballroom

32. Cine-Fluorography in the Evaluation of Neuromuscular Diseases of the Esophagus.

Frederick S. Cross, Earle B. Kay and George F. Johnson

(by invitation), Cleveland, Ohio

It was the purpose of the present study to evaluate cine-fluorography as a technique in the diagnosis and investigation of certain neuromuscular disorders of the esophagus.

A total of 55 patients with the following categories of esophageal disorders have been studied by means of cine-fluorography, as well as intra-esophageal pressure studies, routine fluoroscopic and x-ray examinations, and esophagoscopy when indicated-

1. Neuromuscular failure

2. Segmentation

3. Achalasia

4. Diverticula

5. Hiatal hernias

Cine-fluorographic and intraluminal pressure studies have been found to be of great aid in evaluating dysphagia caused by any of the above mechanisms. The dynamic changes occurring during the mechanism of swallowing are permanently recorded in a dynamic manner rather than as static x-ray films which frequently miss or inadequately record the important events.

This study has emphasized the fact that the various types of neuromuscular imbalance existing in the esophagus are not necessarily distinct entities but rather gradations or variations of the same basic problem. They may be primary with no apparent underlying etiology or they may be secondary to the presence of a primary lesion, such as gastric or duodenal ulcer, obstruction at the esophagogastric junction, or a hiatal hernia. The various types of neuromuscular imbalance may exist in combination with each other and frequently have been found to be the underlying etiological factor in the development of such secondary manifestations as diverticula of the esophagus.

The techniques used in the study will be discussed and motion pictures of normal and abnormal esophageal function as demonstrated by cinefluorographic studies correlated with intraluminal pressure studies will be shown. Special emphasis will be placed on the underlying neuromuscular in-coordination frequently found associated with diverticula and hiatal hernias.

33. Esophageal Hiatus Hernia of the Diaphragm-An Analysis of Surgical Results.

George H. Humphreys II, Jose M. Ferrer, Jr. (by invitation) and

Philip D. Wiedel (by invitation), New York, N. Y.

This is a study of 99 cases of esophageal hiatus hernia which were surgically repaired at Columbia-Presbyterian Medical Center from 1940 through 1954. There has been a post-operative follow-up of 2 to 9 years. Pre-operative symptoms and indications for surgical repair are analyzed and correlated with post-operative clinical and roentgenological results.

39 of the 99 cases were over 60 years of age, and 12 of the 99 were over 70 years old. 13 of the 39 cases over 60 years of age were classified pre-operatively as poor risks.

The post-operative clinical results are:

55%-Good

26%-Satisfactory

14%-Poor

5%-Operative or early post-operative deaths

Post-operative roentgenological results are:

47%-No recurrence or persistence

31%-Insignificant small recurrence or persistence

22%-Large recurrence or persistence

A comparison of clinical with roentgenological results is made, deaths are analyzed, and the results are correlated with technique of repair in order to bring out causes of surgical failure. A technique is described which has now been used in a group of these cases over a sufficiently long period to demonstrate its superiority in long term results over other methods used.

34. An Operation for Hiatus Hernia with Short Esophagus.

J. Leigh Collis (by invitation), Birmingham, England.

The operation described has been developed as a result of a series of anatomical and physiological investigations into the problem of hiatus hernia. The first result of these was a re-fashioning of standard operative technique for this condition. These investigations and the re-fashioned operation have already been described in Thorax of September 1954. The essential part of this operation was to obtain an acute angle of implantation between the esophagus and the fundus of the stomach. Experience with it has demonstrated that the valvular mechanism obtained is very effective and that it can even work despite gastric tissue being left above the diaphragm. Technically it is impossible to produce a satisfactory angulation if there is a bulk of stomach tissue passing through the esophageal hiatus. From this point it is a short step to the development of a technique which will reduce the size of the stomach tube and allow an acute angle of implantation between the tube in the chest and the fundus of the stomach below the diaphragm. This operation has been used to meet the problem of short esophagus in nine patients and the experience of this is described.

35. Traumatic Rupture of the Diaphragm-Clinical Manifestations and Surgical Treatment.

Gerard Desforges (by invitation), John W. Strieder, Joseph P. Lynch

and Irving M. Madoff, Boston, Mass.

Traumatic rupture of the diaphragm is becoming a more frequent problem apparently as the result of an increasing number of accidents associated with rapid deceleration. The diagnosis has not been made easily, usually, as evidenced by the number of late diaphragmatic ruptures one is called upon to repair. However, if the possibility of this entity is considered, the diagnosis can be suspected quickly, and prolonged disability can be avoided Early diagnosis assumes additional importance in terms of its medico-legal aspects.

The clinical picture of diaphragmatic rupture may be conveniently divided into three phases: An immediate phase, a chronic phase, and an intermediate, or dramatic phase. In the immediate phase, the diagnosis understandably is often obscured by associated serious injury. In the chronic phase, the diagnosis may be confused with vague chronic gastro-intestinal disease. In the intermediate phase, the diagnosis concerns strangulation or obstruction of abdominal viscera. Emergency surgical therapy may occur under less than ideal circumstances at this time.

An analysis of the histories of sixteen patients with ruptured diaphragm treated by the authors forms the basis of this report. It is the purpose of this communication to review the etiological mechanism, to elaborate on the clinical syndromes aforementioned, to point out the radiological aspects and to outline the surgical therapy of this disease entity. The pertinent surgical literature is reviewed.

36. Reconstruction of the Esophagus with Segments of the Colon.

William E. Neville (by invitation)

and George H. A. Clowes, Jr., Cleveland, Ohio

To evaluate the reconstruction of the esophagus by implanted colon, not a new concept, a series of dogs were submitted to this operation. In none of the survivors has ulceration of the colon or remaining esophagus been demonstrated despite consumption of normal diet. This is in contrast to dogs with a portion of the stomach in the chest, some of which develop esophagitis.

Eighteen patients were subjected to intrathoracic replacement of the esophagus by a colonic segment for both benign and malignant esophageal lesions. Of these, thirteen survive now. All gained weight postoperatively and showed improvement in their nutritional state as measured by hemoglobin, total protein, and strength. There has been no evidence of esophagitis or ulceration of the colon segment by x-ray and esophagoscopy.

This paper will present the follow up data on these patients which will range in period of from one to three years. Certain suggestions for operative technique which have come from this experience will be discussed.

37. Primary Tumors of the Heart: A Surgical Problem.

J. Gordon Scannell and Hermes C. Grillo (by invitation), Boston, Mass

The authors present 2 successful excisions of primary tumors of the heart. One, a myxoma of the left atrium was removed intact by cardiotomy under hypothermia. The patient, a man of 32, is living and well 18 months post-operatively. The second, a low-grade fibro-sarcoma of the right atrium was removed nine months ago. The patient, a girl of 7, is presently well without evidence of recurrence.

An additional patient, aged 9, thought to have rheumatic heart disease, died of a cerebral embolus while awaiting diagnostic studies. Autopsy disclosed a removable myxoma within the left atrium.

With increasing numbers of cardiac operations, primary tumors of the heart are certain to be encountered with greater frequency. Their diagnosis and management, therefore, assume great clinical significance. The authors propose to review briefly the clinical features and natural history of this group of tumors.