Friday Afternoon, May 13, 1960

2:00 P.M. Scientific Session: REGULAR PROGRAM Napoleon Room

37. Clinical Experiences with Fifteen Patients with Traumatic Rupture of the Thoracic Aorta.

Frank C. Spencer, Paul F. Guerin (by invitation), Hu A. Blake (by invitation),

Washington, D. C., and Henry T. Bahnson,

Baltimore, Md.

Fifteen patients have been seen with a ruptured aorta from injury in an automobile accident or other thoracic trauma. Seven were seen shortly after injury; eight were seen with a thoracic aneurysm six months to sixteen years after injury. Six of the seven patients treated shortly after injury had rib fractures but only four were hypotensive. The chest roentgenogram showed widening of the mediastinum in every patient and a hemothorax in four patients. The diagnosis was delayed or missed in all but one of the patients because of the absence of signs of serious injury and erroneous interpretation of the widened mediastinum on the chest roentgenogram; in one patient the diagnosis was made by emergency aortography. Five patients who did not receive any definitive treatment died suddenly from massive hemorrhage 3, 12, 14, and 24 hours and 3 weeks after injury; two patients were operated upon, one of whom recovered.

Seven of the eight patients with a thoracic aneurysm were successfully treated by excision of the aneurysm and replacement with a plastic prosthesis while the distal blood flow was maintained with left atrial-femoral bypass. One fatality resulted from hemorrhage during attempted excision of a huge aneurysm which had suddenly enlarged and occluded the left main bronchus sixteen years after injury.

The aortic injury in all fifteen patients was a partial or complete transverse tear just distal to the left subclavian artery. The consistent location and nature of the injury makes it readily amenable to surgical treatment if the correct diagnosis can be made

The presentation includes clinical and roentgenologic findings that suggest the diagnosis, photographs of the area of rupture of the aorta, and experiences with the operative management of these patients

38. Surgical Management of Penetrating Injuries of the Ascending Aorta and Aortic Arch.

Walter L. Diveley, Rollin A. Daniel, Jr., and

H. William Scott, Jr., Nashville, Tenn.

We have encountered three patients with penetrating injuries of the aorta. These include:

1 A patient with a traumatic ductus arteriosus produced by a pistol wound.

2. A patient in whom a piece of heavy wire was propelled into the ascending aorta by a rotary lawn mower.

3. A patient who was stabbed with a knife sustaining a traumatic aorticopulmonary fistula and also a fistula between the proximal pulmonary artery and the left atrium.

The diagnostic methods used and the surgical management of each patient will be discussed. The lesion was corrected in each instance and all of the patients recovered from the operative procedure.

39. Antibiotics and Extracorporeal Surgery.

C. Frederick Kittle, and William A. Reed

(by invitation), Kansas City, Kan

Since the advent of antibiotics their use in many surgical instances has become prophylactic. The occurrence of antibiotic reactions and the development of antibiotic-resistant organisms have focused attention on this problem and demanded scrutiny of indications for antibiotic administration.

Our data are derived from the use of antibiotics in consecutive patients undergoing extracorporeal operative procedures for a variety of conditions (both congenital and acquired heart diseases).

Antibiotics were used routinely in patients undergoing extracorporeal circulation until April 1959; subsequently no antibiotics have been given without specific indications. In the 86 consecutive patients studied to date (those surviving for one week or more) 34 received broad spectrum antibiotics prophylactically; 40 received no antibiotics nor were antibiotics used in preparation of the blood; and in the remaining 12 patients antibiotics were given postoperatively for various reasons

In the group receiving antibiotics prophylactically there were three hemolytic staphylococcal wound infections (minor), two with pneumomia who subsequently died, and one with a Pseudomonas bacteremia who died. In those who received no antibiotics there was one hemolytic staphylococcal wound infection (minor). Twelve patients received antibiotics for the following indications: pneumonia or pneumonitis - 3, wound abscess - 1, staphylococcal septicemia - 1, and fever, cause undetermined, 7

The average duration of postoperative fever was essentially the same in the group receiving no antibiotics as in the group receiving them prophylactically

These studies are continuing but there seems no evidence to warrant the use of or to suggest that prophylactic antibiotics are advantageous m patients having extracorporeal perfusion Specific indications of an active infectious process should be present before use of these agents. A similar conclusion has been reached after evaluating antibiotics in other types of cardiovascular procedures not employing use of the extra-corporeal machine.

40. Achalasia of the Esophagus in Children.

Orvar Swenson, and Chris T. Oeconomopoulos (by invitation),

Boston, Mass.

Achalasia or cardiospasm is a rare condition in children and little concerning the condition in this age group is available in the medical literature. We have reviewed our experience with six cases.

Strip biopsies were secured from the lower esophagus in two patients and these contained no ganglion cells. Similar strips of tissue were removed from the normal esophagus at post-mortem and these contained numerous ganglion cells. Peristaltic studies were made and these demonstrated good propulsive function in the esophagus.

The similarity of this condition to that in adults is indicated. Pathologic studies in adults have been made by several investigators and a degenerative lesion of Auerbach's plexus of the lower esophagus has been demonstrated. It is postulated that in children the defect is the same except that the lesion is congenital in origin.

The problem of diagnosis in this obscure condition is discussed. The effectiveness of dilatation in four cases and surgery on the lower esophagus in two cases is given on the basis of two to eight year follow-up studies.

41. Objective Evaluation of Surgery for Hiatus Hernia and Esophagitis.

Lucius D. Hill, and Kyle W Chapman (by invitation),

Seattle, Wash

In spite of the increasing frequency with which hiatus hernia and peptic esophagitis have been attacked surgically, there have been few attempts made to objectively evaluate these conditions with reference to the effect of surgery on the underlying pathophysiology.

In reviewing the data on over 175 patients operated upon for hiatus hernia and esophagitis, it was difficult to objectively determine the severity and degree of esophagitis present preoperatively and the actual effect of surgery on the underlying disease.

This paper presents the results of studies of the mechanisms of reflux esophagitis and the effect of surgery on these mechanisms. A method of simultaneous measurement of pH and pressure in the esophagus, and the pH and pressure changes at the gastroesophageal junction will be described. Over 40 patients have been studied by this method. In this group we have studied both the normal subject and patients with esophagitis ranging in severity from the mild forms to stenosing esophagitis with obstruction. Patients with recurrent hiatus hernia and esophagitis following surgery have also been studied Both pre- and postoperative measurements of pH and intraesophageal pressures have been obtained in patients with various types of operations ranging from simple repair of the diaphragmatic hiatus to complex operations utilized for correction of severe stenosing peptic esophagitis. These determinations give the surgeon an objective measurement of the degree of underlying pathology and the effect of surgical operations upon the disease.

On the basis of over 175 operations, as well as experimentation, recommendations are made relative to the adequacy of various surgical operations. Certain procedures can be shown to be definitely inadequate by these direct measurements.

42. Instrumental Perforation of the Esophagus.

Thomas F. Nealon, Jr., John Y. Templeton III, Vincent D. Cuddy (by invitation),

and John H. Gibbon, Jr., Philadelphia, Pa

Even in the hands of expert endoscopists an occasional instrumental perforation of the esophagus occurs. With antibiotics available, some surgeons and endoscopists have advocated nonoperative treatment, or have delayed surgical intervention. Our experience with this complication does not support this point of view.

During the past six years 18 instrumental perforations of the esophagus occurred at the Jefferson Medical College Hospital. The perforation was produced by an esophagoscope in 12 patients, by a gastroscope in 3 and by a bougie in 3. The ages of the patients ranged from twenty months to 74 years. All patients were operated upon between two hours and 21 days after the perforation occurred. The surgical procedures ranged from simple drainage to esophagectomy. Five of the 18 patients died as a result of the perforation. One death occurred among the 11 patients operated upon within 24 hours of the perforation. Four deaths occurred in the 7 patients operated upon more than one day after the perforation. This experience leads us to believe that conservative treatment by antibiotics, nasogastric intubation, or gastrostomy is dangerous, and that early operative intervention is indicated.