Tuesday Afternoon, April 21, 1959

2:00 P.M. Scientific Session: REGULAR PROGRAM -Pacific Ballroom

7. The Surgical Management of Complications of Staphylococ-cal Pneumonia in Infancy and Childhood.

David C. Sabiston, Jr., Edward W. Hopkins (by invitation), and

Robert E. Cooke (by invitation), Baltimore, Md.

With the increasing incidence of antibiotic resistant strains of the staphylococcus, clinical problems presented by infections with this organism have become of considerable importance. One disease in which a striking rise has occurred is staphylococcal pneumonia. This disease was formerly characterized by its low incidence and high mortality. In a series observed during the past three years at the Johns Hopkins Hospital there have been 67 cases. In this group 62 (92%) were primary. Five (8%) were secondary to some other systemic illness (cystic fibrosis of the pancreas, nephrosis, hypogammaglobinemia). The complications which may follow staphylococcal pneumonia include: (1) empyema, (2) tension pneumothorax, (3) pneumatoceles, (4) persistent abscess, and (5) fibrotic pleurisy ("captive lung"). Of the entire group 29 (43%) have required some form of surgical therapy. The procedures employed have included: (1) closed intercostal catheter drainage, (2) rib resection with open drainage, and (3) pulmonary decortication. In addition all patients have received large doses of antibiotics. The mortality in the primary group was 7% and for the five patients in the secondary group 100%.

As an example of the magnitude of this problem as a postoperative complication, the case of a young patient with coarctation of the aorta may be cited. During recovery following operation of the coarctation, the patient developed a staphylococcal pneumonia and empyema overlying the site of the aortic anastomosis. Prompt open drainage and massive intravenous antibiotics resulted in a complete recovery.

8. Surgical Treatment of Pulmonary Coccidioidomycosis: Ten Year Study.

Bert H. Cotton and J. W. Birsner (by invitation), Pasadena, Calif.

This paper represents further observations of Coccidioidomycosis which is a follow-up of a preliminary report of 30 cases presented before this Association in 1950. The material represents 1500 cases of which 120 have received surgical treatment.

The x-ray, pathologic and bronchoscopic findings plus symptoms have been correlated to predict the course and termination of the pulmonary manifestations of Coccidioidomycosis and the complications, thus, crystalizing the indications for surgical treatment of cavities and granulomas.

Since there has been considerable divergence of opinion as to the proper treatment for these focalized lesions, we hope this paper will contribute to a more uniform approach in management. The complications of surgical treatment are listed, and possible causes are suggested.

9. The Effect of Mean Endotracheal Pressure on the Cardiac Output of Patients Undergoing Intrathoracic Operations.

Thomas F. Nealon, Jr., Richard T. Cathcart (by invitation),

William Fraimow (by invitation), Edward D. McLaughlin

(by invitation), and John H. Gibbon, Jr., Philadelphia, Pa.

Previous work from this laboratory demonstrated that an increase in mean endotracheal pressure causes a significant decrease in the cardiac output of patients undergoing intra-abdominal operations. Changes in the cardiac output were related only to changes in the mean endotracheal pressure and were independent of any other single component of the time pressure pattern employed. The present study is concerned with the effect of the mean endotracheal pressure on cardiac output of patients undergoing intrathoracic operations.

The patients were anesthetized with ether and oxygen administered via a circle anesthetic system which included a cuffed endotracheal tube. Ventilation was provided by an intermittent positive and negative pressure ventilator. Five mg. of Evans Blue dye (T-1824) were injected via a catheter into an axillary vein. A sample of arterial blood was drawn at a constant rate directly from a brachial artery into a cuvette densitometer. Endotracheal pressures and the dye dilution curve were recorded on a multiple channel oscilloscope. Cardiac outputs were measured after a suitable period of stabilization: (1) after the operation was begun but before the chest was opened (a) with a mean endotracheal pressure of approximately 3 cm. of water and (b) with a mean endotracheal pressure of approximately 15 cm. of water and (2) after the chest was opened employing the same two mean endotracheal pressures.

In conformity with our previously reported observations, a significant decrease in cardiac output occurred when the mean endotracheal pressure was increased before the chest was opened. However, when the chest was open, no change in cardiac output resulted from a similar increase in the mean endotracheal pressure.

10. Injuries of the Trachea and Major Bronchi.

R. Maurice Hood, Austin, Tex., and Herbert E. Sloan, Ann Arbor, Mich.

Injuries of the trachea and major bronchi which have been but rarely diagnosed in the past are now occurring with rapidly increasing frequency. Repair of such injuries without sacrifice of lung tissue and with prevention of serious respiratory disability or death is feasible in the majority of cases.

Seven patients sustaining injuries of this type will be presented.

An analysis of all cases since the last complete review of this subject by Kinsella, in 1947, will be presented. From these data it will be shown that despite the relative ease with which early diagnosis may be established, the nature of the injury frequently has not been suspected for weeks or even months. Far too often resection has been utilized even in recent years.

The purpose of this study will be to emphasize the symptoms and findings presented by patients with injuries to the trachea or bronchi during the first few hours following injury. These findings will be compared with those characteristic of the late post-injury period.

The useful diagnostic procedures, in the acutely injured patient and in cases where initial diagnosis has been missed, will be discussed. The management of the diagnosed early injury and the methods of surgical treatment of the late injury will be discussed. The authors' cases will be used to illustrate problems of diagnosis, treatment, and complications which may occur.

11. Adverse Surgical Experience in the Treatment of Pulmonary Disease Caused by Atypical Acid-fast Bacilli.

Robert W. Harrison (by invitation), Arthur F. Reimann (by invitation),

Edwin T. Long (by invitation), William Lester, Jr. (by invitation),

and William E. Adams, Chicago, Ill.

The use of reliable bacteriological techniques has led to increased recognition of the role of "atypical" acid-fast bacilli in human pulmonary disease. In our experience, 35% of patients with positive sputum cultures have "atypical" acid-fast bacilli in their cultures. These cultures are classified on the basis of growth characteristics and morphology into three major groups: (1) Photochromogenic; (2) Skotochromogenic; and (3) Indeterminate.

The photochromogenic group is of greatest clinical interest. These cultures uniformly show elevated resistance to the standard anti-tuberculous drugs and patients infected with them respond very poorly to conventional therapy. To date, photochromogenic cultures have been obtained from 88 patients with pulmonary disease and 27 surgical procedures (resections and/or thoracoplasties) were performed on 22 of them. This group had a 40% rate of post-surgical complications or reactivations of disease, representing failures of surgical treatment. This rate of failure was found to be more than twice that observed for comparable patients infected with typical tubercle bacilli or other types of atypical organisms. Pulmonary resections in cases of photochromogenic infection were found to have an especially high incidence of complications. Histopathologic studies on resected and autopsy specimens from these cases have suggested certain explanations for these results.

This experience has modified our views on the surgical management of patients infected with atypical photochromogenic acid-fast bacilli. As a result, our present philosophy towards the surgical treatment of photochromogenic infections is not dissimilar to the earlier attitude regarding the role of surgery in tuberculosis prior to the advent of chemotherapy.

12. The Surgical Treatment of Tuberculosis in Children.

Walter W. Fischer, New York, N.Y.

Prior to the use of specific antibiotics, surgery had very limited application in the treatment of tuberculosis in children. Antibiotic therapy has radically altered the prognosis of both complicated primary and reinfection tuberculosis in children, so that excisional therapy now has occasional useful application. This report is based on a group of thirty-eight children who have been subjected to excisional surgery on the pediatric service at Bellevue Hospital during the past six years. These included five pneumonectomies, sixteen lobectomies and sixteen segmental resections. The youngest child was one year and seven months of age, the oldest fifteen. The average age was seven and one half. Eight were considered to have reinfection type of tuberculosis. The remaining thirty had surgery because of the complications of primary tuberculosis. In this group lies the difference in indications for surgery in children and adults. The discussion is directed primarily to the complications of primary tuberculosis that may require surgical intervention, namely, progressive primary disease and post-primary disease.

In post-primary disease we are dealing with patients whose tuberculous infection may be largely controlled but in whom irreversible pathologic changes have occurred as a result of the primary infection. The role of the lymph node component of primary disease and its relation to endobronchial disease is discussed. Bronchoscopy and bronchography are essential in evaluating these patients. The presence of bronchiectasis as well as x-ray evidence of persisting obstructive lesions involving segments, lobes, or entire lungs are the most common indications for surgery. Representative cases are presented.

13. Persistent Pleural Air Space Following Resection for Pulmonary Tuberculosis.

T. W. Shields (by invitation), Wm. M. Lees, R. T. Fox,

and G. Salazar (by invitation), Chicago, Ill.

A persistent pleural air space following resection for pulmonary tuberculosis has been encountered frequently in recent years. The significance of such a space varies from complete benignancy to that of a fatal complication. To evaluate this problem the roentgenograms and clinical records of 100 individuals presenting a pleural air space persisting longer than two weeks post-resection (lobectomy, segmentectomy, and wedge resection) have been reviewed. Of these 100 air spaces 60 caused no symptoms and, though some persisted as long as 24 months, produced no adverse effect on the patient's clinical course. The remaining 40 air spaces caused such symptoms as pain, cough, dyspnea, hemoptysis and fever, and required operative intervention of varying magnitude for their control. Thoracoplasty was necessary in 19 patients, closed tube drainage in 12, and multiple aspirations, pneumoperitoneum or phrenic nerve crush, alone or in combination were successful in obliterating the space in the remaining 9 patients of this symptomatic group. The most serious complications were bronchopleural fistula and empyema, and these led to chronic invalidism or death in 5 patients. The etiology, prevention, and treatment of these air spaces are discussed and the early clinical differentiation between the benign space and the potentially hazardous one is emphasized.