Thursday Morning, April 23, 1959

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

31. Instantaneous Blood Loss Determination in Thoracic Surgery.

Robert Klopstock, Harry H. Leveen (by invitation), and

Phillip I. Levitan (by invitation), Brooklyn, N.Y.

At the Clinical Congress of the American College of Surgeons in 1957, an apparatus (Blood Loss Monitor) was described which instantaneously determined operative blood loss by a method utilizing electrical conductivity. The present report presents the results of studies in excess of 60 major thoracic surgical cases.

The blood loss in thoracic operations may be of considerable magnitude because these procedures are prolonged and because the largest vascular structures of the body are the ones involved in the surgical manipulations. Accidents are likely to cause profuse and sudden blood loss. Established estimates of blood loss in routine thoracic surgical procedures (including cardiac operations) are subject to wide variations and cannot be applied to the management of any individual case. The accuracy and the rate of blood replacement cannot and should not be related to the vital signs, since the undesirable physiologic changes have already occurred when they become detectable. Over-transfusion, on the other hand, produces a syndrome not unlike that of shock. Instantaneous monitoring of operative blood loss appears to be mandatory in cardiovascular procedures carried out under hypothermia. Continuous and instantaneous measurement of operative blood loss avoids these pitfalls. The conductivity method for measuring blood loss allows for continuous and instantaneous determination.

When blood replacement was made according to the loss indicated by the Monitor, erythrocyte concentrations, hemoglobin and hematocrit values on the following postoperative days failed to show significant changes as compared with the pre-operative determinations. Wide swings in operative pulse rates and blood pressures did not occur even m instances where the loss was as great as 4000 cubic centimeters in fifteen minutes.

Illustrative cases will be presented and a short film will be shown.

32. Experiences with the Treatment of Postoperative Cardiac or Respiratory Failure with a Mechanical Respirator.

F. C. Spencer, D. W. Benson (by invitation), W. C. Liu

(by invitation), and H T. Bahnson, Baltimore, Md.

Ventilation with a mechanical respirator has been found of considerable value in the treatment of postoperative cardiac failure or respiratory insufficiency. Experience to date includes 9 patients who recovered after the use of a respirator for 2 to 40 days. Three patients had respiratory insufficiency following a crushing injury of the chest, a pneumonectomy with repeated cardiac herniation, and a decortication, respectively. Six patients had an intracardiac defect repaired with extracorporeal circulation; the defects included ventricular septal defect, tetralogy of Fallot, atrial septal defect with pulmonary hypertension, and mitral stenosis and insufficiency. The cardiac and respiratory failure in all of these patients was so severe that survival seemed unlikely before a respirator was employed.

A piston respirator attached to a tracheostomy tube was used in all instances. Serial determinations of the arterial pH and oxygen saturation were made on all patients, and cardiac output studies were done on some. The indications and the techniques employed with the respirator will be presented.

33. Intrathoracic Complications of Subdiaphragmatic Infection.

David P. Boyd, Boston, Mass.

A study of 115 cases of subphrenic infection seen at the Lahey Clinic in the past few years forms the basis for this report. A number of these cases showed interesting complications within the thorax.

The surgical and pathological anatomy of the diaphragm and suprahepatic spaces has been a source of confusion to students in the past. An attempt has been made to simplify this anatomy and pathology on the basis of anatomical studies and clinical findings.

Intrathoracic complications of Subdiaphragmatic infections are increasing because of the attenuation of these infections by modern methods of treatment. The chronicity of Subdiaphragmatic abscess today may have resulted in an increased frequency of intrathoracic complications. Examples will be cited in which the first symptom of infection below the diaphragm was the profuse expectoration of purulent material.

We have seen cases of bilateral subphrenic infection with bronchial fistula. These patients may not require pulmonary surgery if the Subdiaphragmatic infection is adequately drained. The importance of adequate drainage is emphasized by reference to case reports of patients who have died of fulminating bronchopneumonia as a result of acute massive perforation of such an abscess through the diaphragm into the bronchial tree.

A most interesting group of cases (closely related to the above) are those with bronchobiliary fistulas. We have seen a number of patients with postoperative strictures of the bile ducts who have accumulated subphrenic collections of bile which in turn perforated into the free pleural cavity. These are cases of pleurobiliary fistula. Other patients with pleural fusion have developed bronchobiliary fistula. Examples in each category will be shown.

34. The Early Elective Surgical Approach to the Treatment of Traumatic Hemothorax.

Morris M. Culiner (by invitation), Benson B. Roe,

and Orville F. Grimes, San Francisco, Calif.

The prevailing concepts of the treatment of traumatic hemothorax should probably be altered. The conservative approach to the problem is often unsatisfactory. Two major concerns exist, namely, (1) prevention of exsanguina-tion and death, and (2) preservation of pulmonary function and reserve. In the latter instance, surgical maneuvers are often unduly delayed.

An early elective surgical approach to patients with residual hemothorax, remaining after needle or tube thoracentesis, has provided a method of control of expansion of the lung, obliteration of the pleural space, prevention of empyema, and has materially decreased the period of hospitalization.

In a series of 43 patients who sustained traumatic hemothorax, 10 patients have been operated upon for residual massive clotted or unclotted hemothorax from one to fourteen days after injury. The technical ease of evacuation of the pleural space and the manner in which lung expansion can be attained suggest that the early aggressive approach is preferred. The concept of the treatment of clotted hemothorax by decortication after a waiting period of three to six weeks following trauma may be justifiably questioned.

35. The Surgical Treatment of Peptic Esophagitis.

Frederick S. Cross, George V. Smith, Jr. (by invitation),

and Earle B. Kay, Cleveland, Ohio

Interest in peptic esophagitis as a specific clinical entity has been increasing since the first description of this disease in 1934. Much of the impetus given this interest has come from surgeons in devising operative procedures for its correction ranging from a simple pyloroplasty, to gastric resection, to complicated plastic procedures on the esophago-gastric junction.

It is the purpose of the present report to reiterate the role of hiatal hernia in the production of peptic esophagitis, and to emphasize reconstitution of the cardiac sphincter mechanism as the logical treatment of this disease.

Since January, 1949, 125 patients with esophagitis of varying severity have been seen. In virtually all patients the presence and degree of esophagitis have been confirmed by esophagoscopy. Ninety-eight, or 78% of the patients studied, had an associated hiatal hernia. In the remaining 27 patients no hiatal hernia could be demonstrated. The etiological factors such as severe vomiting, the presence of an inlying gastric tube, or an associated duodenal or gastric ulcer in this latter group will be discussed.

In 60 patients with hiatal hernia and esophagitis, the hiatal hernia was repaired with uniformly good results; whereas, conservative therapy for esophagitis in the presence of a hiatal hernia gave uniformly poor results. Conservative therapy for esophagitis without the abetting factor of a hiatal hernia was more satisfactory. The results of hiatal hernia repair in the treatment of esophagitis will be related in detail along with our experience with other procedures that have been suggested for the treatment of severe stricturing esophagitis.

A proposal for the surgical reconstitution of the cardiac sphincter mechanism in those patients without a demonstrable hiatal hernia but with significant esophagitis will be discussed.

36. Utility of a New Procedure of Valvular Esophagogastrosto-my in Cases of Brachyesophagus and Stricture: Clinical and Experimental Studies.

David H. Watkins, William R. Rundles (by invitation), and

Louis Tatom (by invitation), Denver, Colo.

Regurgitation esophagitis and peptic ulceration at the esophagogastric junction is an important problem at the present time. Different forms of incompetence of the cardia have been described. However, one should principally consider mechanical factors as causes of significant cardial incompetence. Studies both experimental and clinical of the factors responsible for competence of the gastric cardia have shown the significance of the diaphragmatic crura, the angle of His, the sling muscle of the lesser curvature, and the valve of Gubaroff. The pathogenesis of esophagitis is attributable to the deficit of one or several of these factors which causes the gastric juice to flow back and forth and to attack the susceptible esophageal mucosa. Etiologically, various organic causes (sliding hiatus hernia, absence of the greater tuberosity of the stomach) and functional causes are to be distinguished. Reflux esophagitis begins with acute esophagitis and ends with the strictured brachyesophagus.

While subtotal gastrectomy or vagotomy with gastroenterostomy diminishes the effects of gastric reflux into the esophagus, the stenosis frequently persists. Esophagitis may continue despite resection of the area and esophagogastrosto-my or cardioplastic operations. Lower esophageal and upper gastric resection with esophagoantrostomy may be impossible because of the length of esophagus involved. Total gastrectomy even with restoration of continuity utilizing the transverse colon may be inadvisable.

The experimental findings which form the basis of a modified valvular esophagogastrostomy, which has been used by us clinically with gratifying results, will be presented. Illustrative cases in which the operation has been carried out will be shown.