Wednesday Morning, April 18, 1962

8:30 A.M. Scientific Session: REGULAR PROGRAM Khorassan Room

29. Clinical and Pathological Characteristics of Carcinosarcoma of the Esophagus

James L. Talbert (by invitation), Baltimore, Md., and

James R. Cantrell (by invitation), Seattle, Wash.

Sponsored by Alfred Blalock, Baltimore, Md.

The distinctive clinical and pathological characteristics of carcinosarcoma of the esophagus are of sufficient therapeutic import to warrant special emphasis despite the relative rarity of the lesion In contradistinction to the more common epidermoid carcinoma, carcinosarcoma is typically a polypoid lesion and exhibits a strong tendency to remain localized within the limits of the esophageal wall Direct invasion of adjacent structures, lymphatic spread and distant metastasis occur only late in the disease. The therapeutic approach to this neoplasm must be based upon these specific characteristics. Curative resection should be feasible in a high proportion of cases. The evidence pertinent to these considerations will be reviewed. A series of four cases will be presented to illustrate the characteristic diagnostic and pathological features of this tumor.

30. Columnar Epithelium Lining the Lower Esophagus: Association with Hiatal Hernia, Esophagitis, Ulcer, Stricture and Tumor

Richard H. Adler, Buffalo, N. Y.

The lower portion of the esophagus has been found to be lined by columnar epithelium in five patients followed for periods up to three years. In each instance there was an associated hiatal hernia. All had a short stricture well above the hiatal hernia at the level of the aortic arch, initially diagnosed as carcinoma in most instances. Another individual had a typical punched-out "gastric" ulcer in the mid-esophagus in columnar epithelium well above a hiatal hernia. An additional person had an adenocarcinoma in the distal esophagus above a hiatal hernia In four other patients with hiatal hernias, progressive strictures observed over periods up to five years were found to have associated columnar epithelium in the strictured area. Esophagoscopy for dilatation of strictures and for multiple serial mucosal biopsies formed an integral part of diagnosis and treatment Although the lower esophagus lined by columnar epithelium is generally held to be a congenital anomaly, the author will present a concept that this represents an adaptive replacement of squa-mous epithelium related to reflux digestive esophagitis; also, that the most distal esophagus may have a variable amount of columnar epithelium under normal conditions Evidence gathered from a study of over 250 postmortem esophagi suggests that the esophageal glands may play a significant part in this epithelial replacement Discussion will include practical considerations of the associated ulcers, strictures and tumors.

31. Combined Prosthetic Replacement of the Aortic and Mitral Valves Using a Left Atrial Approach

Robert S. Cartwright (by invitation), James W. Giacobine

(by invitation), William B. Ford, and William E. Palich (by invitation),

Pittsburgh, Pa.

The aortic valve and the ventricular septum may be exposed through the left atrium by incising the aortic leaflet of the mitral valve either perpendicular or parallel to the annulus. Initial experiments in dogs showed that repair following these incisions can result in functional healing of the valve. In subsequent experiments in twenty-one dogs, replacement of the aortic valve with a prosthesis or combined replacement of the aortic and mitral valves was proven technically feasible. This approach permits (1) successful ball valve replacement of the pliable aortic valve in an intact aorta, (2) combined prosthetic replacement of the aortic and mitral valves during an acceptable period of cardiopulmonary bypass, and (3) sufficient exposure of the ventricular septum to permit repair of high ventricular septal defects and (4) direct vision operative treatment of hypertrophic stenosis of the left ventricular outflow tract. Clinical trial has thus far been limited to combined prosthetic replacement of the aortic and mitral valves. Although the time interval since our first application of the method has been too short for final conclusions, survival with dramatic hemodynamic improvement has been obtained. Details of the exacting surgical technic will be presented along with the results of postoperative studies of valve function with phonocardiography, kymography, and cine technics

32. Analysis of Results from Open Operation for Acquired Aortic Valve Disease

Dwight C McGoon, H. T. Mankin (by invitation), and

John W. Kirklin, Rochester, Minn.

In 194 open operations performed for acquired aortic valve disease the technic for calcine types was decalcification (60%), single or double leaflet replacement (25%) or total replacement (15%). Noncalcific incompetence (from rheumatic fever, bacterial endocarditis, or aneurysm of ascending aorta) was treated by plastic revision or by total valve prosthesis. Among 112 cases with isolated calcific lesions, hospital mortality rate was 16% when coronary artery perfusion was used, 36% when external cardiac cooling was used. It was 38% in 42 cases with isolated noncalcific valve incompetence. Mortality was 47% in 40 patients in whom mitral valve lesions demanded concomitant repair. Other factors implicated in deaths included failure to relieve valve pathology, calcific emboli, associated coronary artery atherosclerosis, and complications of prolonged whole body perfusion. Identification of these has allowed some specific measures for minimizing their occurrence. Palliation after surgery is with some exceptions excellent. Attempts to decalcify rather than partially replace extensively diseased calcareous valves sometimes proved inadequate. Among patients with non-calcific incompetence, those treated with total prosthetic reconstruction have shown the best results. Patients with advanced symptoms from cardiac failure have demonstrated the ability to improve markedly with correction of their mechanical valve defect.

33. Internal Mammary Implantation for Coronary Heart Disease: A Clinical Follow-Up Study One to Eight Years After Operation

W. G. Bigelow, H. Basian (by invitation), and

G. A. Trusler (by invitation), Toronto, Canada

Nineteen patients disabled from angina, which was not responsive to medical therapy, have been operated upon one and one-half to eight years ago. The final results of this study are considered surprisingly good. There were 11 patients in the favorable group without angina decubitus. In this group there were no operative deaths, and there were 3 late deaths during the period of follow-up. This small series indicates that survival may be somewhat better than natural life history expectancy. Clinical assessment one and one-half to eight years after operation in the 8 favorable cases are: 2 excellent, 4 good, 1 fair, and 1 no change. Good and excellent cases were back to work. All but one of those tested showed an improvement in exercise ability and symptoms of angina over the preoperative state, and 60% showed improvement in the electrocardiographic changes with exercise. The test that has stimulated this report has been the visual evidence on cineangiography of patency and flow in the implanted internal mammary artery following injection of dye into the subclavian artery at the mouth of the left internal mammary artery. One patient demonstrates this seven and one-half years after surgery. (Movie) Further evidence of patency is found in a. post-mortem study. Injection of the internal mammary artery in this case that died four years after operation showed patency and communication with the coronary arterial tree by vessels of large caliber. It is hoped that this report may stimulate further study and development of this principle.

34. The Postoperative Management of the Severely Ill Patient After Open-Heart Surgery on Cardiopulmonary Bypass

J. F. Dammann, Jr., Nalda Thuno (by invitation),

Ionacio Christlieb (by invitation), W. H. Muller, Jr.,

and James B. Littlefield, Charlottesville, Va.

During the past two years, we have evolved a method of postoperative management which has definitely improved our mortality and morbidity figures in patients with severe aortic disease and chronic left heart failure. Such patients are prone to develop arrythmia, progressive pulmonary insufficiency and have very little cardiac reserve to rely upon during the early period of recovery. The patient is returned to the Recovery Room while under anesthesia and placed on the Engstrom Respirator. Central aortic and central venous pressures are monitored continuously, and arterial and venous blood gas determinations are followed closely. The patient is kept on the respirator under anesthesia or sedatives until the electrocardiogram is stable, cardiac output is reasonably normal, arterial oxygen tension is sufficient, acid base balance has been corrected, blood volume and peripheral vascular tone have returned to normal. Only when these parameters are normal is the patient allowed to waken. The use of the Engstrom Respirator is continued until an adequate level of arterial oxygen tension can be maintained while breathing room air. It is our belief that this method of management after prolonged cardio-pulmonary bypass removes the workload of breathing and the possibility of significant hypoxia during a critical period of readjustment of all organ systems, and thereby materially decreases the risk of sudden death and of major postoperative complications.

35. Bilateral Surgery for Pulmonary Tuberculosis

Thomas W. Shields, Robert T. Fox, and

William M. Lees, Chicago, Ill.

The patient with bilateral tuberculosis continues to be a challenging therapeutic problem. Though a majority of these patients can be successfully managed by the antimicrobial drugs alone, a not small segment of this group requires bilateral surgical intervention for ultimate control of the disease At the Chicago Municipal Tuberculosis Sanitarium approximately 10% of all patients admitted annually undergo a major thoracic surgical procedure; of these 8.5% require bilateral procedures. Since April 1950 to March 1961, 176 patients have completed a bilateral surgical program. Of these 176 patients, there were 97 bilateral resections, 61 bilateral plombage procedures and 18 patients who had resection on one side and a plombage on the other. The bilateral surgical resections were 48 bilateral segmentectomies, 39 lobectomy-segmentectomies, 7 bilateral lobectomies, 2 pneumonectomy-segmentectomies, and one pneumonectomy-lobectomy. The 60 day operative mortality following the completion of the program for the entire group was 2.2% and a total non-fatal complication rate of approximately 25%. The results in the operative survivors were successful in 79% of the patients' a failure (continued active disease) in 7.6% of the patients and 7%of the patients were lost to follow-up. The indications, the timing of, and postoperative problems in these bilateral surgical procedures will be discussed.

36. Surgical Treatment of Cavitary Pulmonary Histoplasmosis

Walter Diveley, Robert McCracken (by invitation),

William Stoney (by invitation), and Vernon McConnell (by invitation),

Nashville, Tenn.

Excision of granulomatous lesions believed to be caused by pulmonary histoplasmosis have been frequently reported. However, there has been no large recorded experience with the excision of cavitary lesions in this disease. This report is concerned with fifteen patients with cavitary disease due to histoplasmosis who were treated by pulmonary resection. One patient was subjected to bilateral resection. The diagnosis was established by demonstrating the organism by culture in thirteen patients. In two patients the diagnosis was based on a positive skin test, histoplasmin complement fixation studies, and the microscopic appearance of the excised tissue. The organism was cultured from the sputum before operation in nine patients None of the patients received Amphotericin The selection of patients for operation, extent of resections performed, postoperative complications and results of treatment are discussed in detail

37. Resection for Localized Air Trapping Pulmonary Disease: Preoperative and Postoperative Function Studies

Joseph L. Lucido, Paul Murphy (by invitation), and

Herbert C. Sweet (by invitation), St. Louis, Mo.

Resection of pulmonary tissue for emphysematous blebs, bulla and related processes is a well established method of treatment, with satisfactory clinical results. The laboratory documentation of benefit in such cases is less well established. This paper presents a series of twenty-four patients in whom preoperative and postoperative studies in the pulmonary function laboratory permits objective appraisal of the value of pulmonary resection in air trapping pulmonary diseases. Under air trapping pulmonary disease we include lobar emphysema, pressurized blebs, bulla and cysts, or combination of these entities. The patients manifested various degrees of dyspnea and respiratory inadequacy, including cyanosis and lethargy. The pulmonary function studies comprised vital capacity, maximum breathing capacity, total lung volume, nitrogen retention, residual air and relation of residual air to total lung volume. There has been striking improvement in these values after pulmonary excision consisting of individual bleb removal, wedge resection, segmental resection or lobectomy. We have not included individuals with a spontaneous pneumothorax secondary to the above lesions. The value of precise function studies and management of these clinical problems is well documented by this correlation of clinical and laboratory data.