Wednesday Afternoon, May 11, 1960

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

7. Studies of Peripheral Vascular Resistance Associated with Total Cardio-Pulmonary By-Pass. I. Peripheral Resistance Under Condition of Normothermia and Normotension.

A. Robert Cordell (by invitation), Merrill P. Spencer

(by invitation), and Jesse H. Meredith (by invitation)

Winston-Salem, N. C

Peripheral vascular resistance (PVR), expressed as cc/min. peripheral flow per millimeter of arterio-venous pressure difference, was determined in 10 dogs before, during and after a 30 minute period of by-pass, using a disc oxygenator.

Cardiac output from the ascending aorta and extracorporeal flow were measured with the Bowman Gray Square-Wave Magnetic Flowmeter.

Normal rectal temperature was maintained within two degrees centigrade. Mean arterial pressure was controlled during by-pass at pre-operative values by pump adjustment. Control cardiac output averaged 87.7 cc/Kg/mm.

Pump output (peripheral flow) during by-pass averaged 70 per cent of control under these conditions. Venous pressure remained around 5 millimeters Hg. except on two occasions when it rose to 15 millimeters Hg for a short period. PVR increased steadily during by-pass.

Cardiac output immediately following by-pass was usually below pre-by-pass values. A-V oxygen difference and blood pH were measured from blood samples throughout the experiments. Total oxygen uptake was calculated from serial A-V oxygen difference and peripheral flow and dropped sharply during the period of by-pass. Interpretation of these data will be made and a short movie shown to demonstrate techniques of the experiments.

8. Lipuria and Lipasemia after Thoracic Surgical Procedures.

F. Price Cossman (by invitation), Federico Adler (by invitation),

and C. Frederick Kittle, Kansas City, Kan.

The occurrence of fat globulemia has previously been demonstrated in patients after severe extremity trauma or major soft tissue operations. Most recently our laboratory has studied postoperative changes in serum hpase and the occurrence of lipuria in patients undergoing a variety of thoracic operations including extracorporeal procedures.

In 19 patients to date 11 have had significantly elevated serum lipase (above 2.0 mgm%) and all have shown lipuria of varying extent in the immediate postoperative period. Six of 8 patients following extracorporeal perfusion have had lipasemia while all have had lipuria. A review of autopsy material in patients dying after perfusion has revealed intravascular fat-staining material in the lungs and kidneys in several instances.

The significance of these observations will be interpreted in respect to the magnitude of the operation, the operative trauma to soft tissue, possible nitrogen release from tissues during extracorporeal perfusion, and effect of the extracorporeal apparatus on circulating chylomicrons.

9. Analysis of 50 Cases of Pulmonary Emphysema, Blebs, and Bullae Treated Surgically.

Jerome R. Head, Theodore R. Hudson, Louis R. Head

(by invitation), and James M. Head (by invitation),

Chicago, Ill

Experience with this group of patients is described. They are analyzed with regard to respiratory physiology, pathology, surgical therapy, and immediate and late results.

The respiratory physiology is altered by three pathologic states: (1) a space-occupying lesion, (2) a generalized process and (3) a combination of the two.

Solitary cysts, blebs, and bullae alter respiratory physiology as space-occupying lesions; obstructive emphysema as a generalized process; and emphysema with cysts, blebs and bullae as both.

The surgical therapy of these conditions has included Monaldi suction, surgical resection, or a combination of the two. At the present time Monaldi suction is reserved for those cases whose respiratory function prohibits resection. This is rapidly being replaced by pre- and post-resection respiratory assistance. Excellent results are obtained in cases of solitary cysts, blebs and bullae by means of resection with or without respiratory assistance. Excellent immediate results but discouraging long term results are obtained in cases of generalized emphysema with cysts, blebs or bullae by means of a combination of surgical procedures. Overall poor results are obtained in cases of generalized emphysema by all modes of surgical therapy.

The cases are tabulated and each group is illustrated by means of clinical course, x-ray findings, pulmonary function studies, surgical pathology and long term follow-up.

10. Lung Abscess in Japan.

Kingo Shinoi (by invitation), Tokyo, Japan.

Since 1938, 550 cases of lung abscess have been treated by the Department of Surgery of Tokyo Medical College. Among these there are 338 cases which belong to the pre-antibiotic age. The author reports on some characteristics of this disease is Japan and the results obtained.

1. Analyses have been made of the etiology in our cases. Lung abscesses following dental operations or tonsillectomy are relatively few in Japan when compared to the world literature.

2. Since the discovery of chemotherapy, we find marked changes in the clinical picture of this disease. The patients who visit our surgical clinic have either a "silent" abscess or a far advanced chronic relapsing form. The picture has changed from the fuso-spirochetal type to the drug resistant staphylococcal lung abscess.

3 As the result of biochemical study of sputum and histologic study of the specimen, it was revealed that sputum in the chronic stage is produced by secretion from increased goblet cells formed in the epithelial layer in the pyofibrotic lesion. Furthermore, the relationship between the degree of hyperplasia of goblet cells and the quantity of sputum were studied in comparison with bronchiectasis. The author concluded that bronchiectasis associated with inflammation and chronic lung abscess should be handled as one and the same disease.

4. Based on studies made upon the cardiopulmonary function in relation to surgical operation, it is found that in patients with excessive expectoration decreased ventilatory and alveolar function develops, leading to latent anoxia and subsequently to pulmonary hypertension. At this point I should like to point out the defect of cardiopulmonary function in a "wet" case and to propose the criteria for operation.

5. The results of treatment in 202 cases belonging to the post-antibiotic age showed a cure rate of 65% by pneumonotomy and 96% by lung resection.

11. A Study of Essential Hemoptysis.

Raymond J. Barrett and William M. Tuttle, Detroit, Mich

Essential hemoptysis is a term used to cover those instances where no significant lesion can be found to account for the patient's symptom Use of the term presumes a negative chest roentgenogram, negative bronchoscopic and bronchographic findings and negative psychology. Where indicated, angiocardiography and cardiac catheterization must also be utilized and should, of course, yield normal results, to allow use of the term "essential hemoptysis." One hundred cases which meet such criteria have been followed for periods ranging from one to eight years These are analyzed in regard to subsequent recurrence of hemoptysis, later development of serious disease, and survival.

12. Ligation and Division of the Bronchus in the Surgical Treatment of Cavitary Tuberculosis.

J. Maxwell Chamberlain, and Thomas M. McNeill

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

Auto-occlusion of the bronchus is one mechanism which leads to closure and healing of a tuberculous cavity. In the pneumothorax era, the dramatic closure of a "tension cavity" occasionally occurred, and on several occasions we had similar experiences when the bronchial dynamics were altered sufficiently by thoracoplasty or phrenic nerve paralysis.

Aware of this method of healing, W. E. Adams attempted in the early 1930's to produce bronchial occlusion endoscopically in animals by silver nitrate cauterization. In 1934, Adams and Vorwald reported their experimental results, and mentioned the use of silver nitrate cauterization in four clinical cases of tuberculosis. In general, the clinical use of endoscopic methods to occlude a bronchus has had little success, yet we believe the fundamental concept is sound.

Auto-occlusion of the bronchus that occurs as the end result of endobronchial tuberculosis is a fortuitous incident in the patient's course. We have observed such occlusions clinically in the main bronchus, and also in lobar, segmental and sub-segmental bronchi

Operative occlusion of the draining bronchus can mimic successfully the naturally occurring event, and provide selective pulmonary collapse. In the last 10 years we have elected to ligate and divide the bronchus in 25 cases, including several bilaterally. These were mostly far-advanced, poor-risk cases, whose organisms were resistant to the standard anti-tuberculous drugs. In spite of this, the operative morbidity was suprisingly low, and the end results in properly selected cases were remarkably good. Space problems, with attendant complications and chest wall deformities, are eliminated.

This single-stage, non-deforming operation will find its greatest usefulness in the far-advanced, poor-risk case whose organisms are drug-resistant, and in whom even a minor surgical complication might prove disastrous.

13. The Culture of Tubercle Bacilli from Resected Specimens of "So-called" Negative Patients.

William P. Coohlan (by invitation), George S. Willauer,

Charles Finebero (by invitation), and Robert G. Johnson

(by invitation), Philadelphia, Pa.

There has been some hesitancy to recommend surgical resection for the patient who shows maximum clearing on X-ray and whose sputum has converted with antimicrobial therapy. Despite the negative sputum, we believe that such lesions contain viable tubercle bacilli. The high relapse rate in such patients is thought to be due to reactivation of these quiescent lesions. With reactivation and spread, the patient's prognosis is not as favorable as it would have been at original target point.

With these facts in mind, the following program was instituted in October, 1952, at the Eagleville Tuberculosis Sanatorium. Following surgery, the resected specimen was routinely opened by the operating surgeon, and smears made directly onto culture media. In 123 consecutive pulmonary resections, 22 patients who have had negative sputum cultures preoperatively, have had positive growth from their resected specimens.

The authors feel that this demonstrates significant viability of tubercle bacilli in lesions from "so-called" negative patients. Pulmonary resection in this group of patients offers a more favorable prognosis for permanent cure.