Wednesday Afternoon, April 29, 1964

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

Grand Ballroom

44. Endoscopic Aspects of Post-Surgical Management of Congenital Esophageal Atresia and Tracheo-Esophageal Fistula

Paul H. Holinger, William T. Brown*, and Dino G. Maurizi*,

Chicago, Ill.

One hundred twenty-nine infants with congenital esophageal atresia, tracheo-esophageal fistula or both were observed on the Endoscopic Service of The Children's Memorial Hospital, Chicago, between 1947 and 1962. Problems involving the larynx, trachea, bronchi or esophagus requiring endoscopic management are reviewed. Associated laryngeal anomalies were common. Eleven infants had laryngeal paralysis, six bilateral, two right and three left cord paralysis. Laryngeal anomalies, edema, paralyses or excessive tracheobronchial secretions necessitated tracheotomy in twenty-four infants. Major tracheal problems occurring at the fistula site included fourteen with granulomas or stenoses, eight with recurrent fistulas and seven with diverticula. Bronchial secretions, chemical bronchitis, atelectasis and bronchiectasis necessitated bronchoscopic or tracheotomy management. Seventy-nine infants were treated for esophageal stenosis, sixty-nine with end-to-end anastomosis, eight with stenosis at esophago-gastric, -colic, of -jejunal anastomosis, and two at cologastric anastomosis. Early recognition and management with various dilatation techniques are discussed.

45. Oesophageal Reconstruction with Left Colon

Ronald Belsey*, Bristol, England

Sponsored by O. Theron Clagett

Certain criteria must be satisfied by any acceptable method of oesophageal replacement (1) simultaneous one-stage oesophageal resection and reconstruction should be possible, (2) sufficient tissue to replace the entire oesophagus must be available when necessary in cases of high strictures, or congenital oesophageal atresia unsuitable for primary anastomosis, (3) the method should be applicable to infants and children, and (4) the mortality and morbidity rates, and the long-term functional results must be acceptable. The use of an isoperistaltic transplant of splenic flexure of colon fulfils these criteria. The operative technique and clinical features in 100 cases of oesophageal obstruction treated by this method of reconstruction will be discussed. The indications for reconstruction in this series were (1) benign strictures, 79 cases, (2) high malignant strictures, 11 cases, and (3) congenital oesophageal atresia, 10 cases. There were 4 postoperative deaths, only 2 directly attributable to the operation. Convalescence has been remarkably smooth in all but two of the remainder. There have been no intra-thoracic anastomotic leaks and no case of recurrent oesophagitis. The long-term functional results will be compared with those that follow other methods of oesophageal replacement especially oesophago-gastrectomy.

46. Assisted Circulation for Cardiac Failure Following Intra-cardiac Surgery with Cardiopulmonary Bypass

F. C. Spencer, B. Eiseman, J. K. Trinkle*, and

N. P. Rossi*, Lexington, Ky.

Four moribund patients with cardiac failure 12-24 hours following intra-cardiac surgery have been treated with 4-6 hours of assisted circulation with a roller pump and a disc oxygenator. All had Class 4 cardiac failure before operation, an adequate surgical repair (mitral and aortic insufficiency, 3, ventricular septal defect with pulmonary hypertension, 1), and a good initial response. Subsequent postoperative monitoring with indwelling left atrial and pulmonary artery catheters showed progressive cardiac failure: mixed venous oxygen saturation 20-30%, left atrial pressure 20-35 mm/Hg., hypotension requiring vasopressors, metabolic acidosis, and severe oliguria. A peripheral veno-arterial bypass of 2-2.5 L/min. in 2 patients increased blood pressure, cardiac output, and urine secretion, but the left atrial pressure remained elevated and one developed a marked increase in pulmonary vascular resistance; both died afterwards. Subsequently a left atnal-femoral bypass of 3-5 L/min. in 2 patients similarly increased peripheral blood flow but also lowered left atrial pressure and did not increase pulmonary vascular resistance. One died but one made a dramatic recovery, even though the cardiac output remained decreased until 3 days later. These experiences indicate the possible value, safety, and effectiveness of assisted circulation with left atrial-femoral bypass.

47. High Flow Total Body Perfusion Utilizing Diluted Per-fusate in a Large Prime System

Robert S. Litwak, B. George Wisoff*, and

Howard L. Gadboys, New York, N. Y.

Reduction of homologous blood requirements in high flow extracorporeal circulation has been accomplished by perfusate dilution up to 57% or total volume in 103 cases. This abstract summarizes volumetric and biochemical data obtained in the last 62 cases in which the diluent employed was a dextrose/Ringers/albumin (DRA) solution. Perfusions were generally conducted at 30°C. with flow rates of 2.0-2.4 L/M²/min. Three groups were studied (a) 16 patients (32% DRA dilution), (b) 40 patients (43% DRA/THAM dilution), and (c) 6 patients (57% DRA/THAM dilution with priming Hct. 21). Perfusions averaged 80, 134, and 106 minutes for the three groups. Immediate postperfusion overinfusion was required for all groups. Normal postperfusion hematocrits were observed in all patients and reflected probable loss of diluent from intravascular space. Moderate postoperative metabolic acidosis occurred with DRA (base deficit - 7) but was absent in both THAM series. All groups showed satisfactory late perfusion pO₂ and pCO₂. Serum electrolytes (Na, K, Cl, Ca) were normal during and after perfusion in all groups. Hemodilution (33-57%) has been well tolerated. Pulmonary and metabolic complications have been less than with whole blood. It appears that the high flow rates achieved compensate for initially reduced oxygen carrying capacity of the diluted blood.

48. Acute Constrictive Pericarditis

Ross Robertson, and Craig Arnold*, Vancouver, B.C.

In 1962 we reported five cases of constrictive pericarditis with evidence that they were not tuberculous in origin but resulted from an acute pericarditis attributed to the Coxsackie virus. Subsequently six additional cases have been seen with a similar history of virus pericarditis antedating the constriction by several months and with negative tuberculin tests. The clinical picture differs considerably from the patient with tuberculous constriction, and early diagnosis is more difficult. Calcification of the pericardium has not occurred. Enlargement of the liver, ascites, and pleural effusion have appeared late and rather suddenly. In some of these patients cardiac tamponade has progressed with great rapidity and operation has been required urgently. Discussion will include the diagnosis of pericardial constriction, the indications and optimum time for operation, and the results of surgery. Because of the acute and insidious onset of the constriction constituting an emergency in some of our patients, "acute" has been added to the title.

49. Myocardial Revascularization by Omental Graft Without Pedicle. Report on 30 Cases Followed Six Months to One and One-half Years.

Arthur M. Vineberg, John Shanks*, Roque Pifarre*,

Rosendo Criollos*, Yutaka Kato*, and K. S. Baichwal*,

Montreal, Canada

The greater omentum arises from the same embryological anlage as the spleen. Primitive characteristics of phagocytosis and the ability to form new blood vessels persist when the omentum is completely detached from the colon, it survives by obtaining blood from surrounding tissues. It forms a capillary circulation in 3 days and arteriolar circulation in 8 days. The ability to penetrate mesenchymal cell layers to obtain its blood supply makes it an important tissue for the relief of myocardial ischaemia. Ameroid occlusion of three major coronary arteries causes 100% mortality. An omental graft without pedicle when attached to the ascending aorta and heart protects 80% of the animals. Large vessels leave the aorta, pericardium and chest wall, enter the omental graft, coronary arteries and myocardium. Thirty patients with extensive coronary artery disease have undergone the omental graft operation. Cine coronary arteriography showed disease in main right (69%), main left (44%), anterior descending (1007₀) and circumflex (87%). Patients with angina decubitas, formerly rejected for implant, have been accepted. Operative mortality has been low, post-operative courses have been similar to implant. There has been no evidence of omental graft necrosis. All cases have improved, some dramatically. Detailed results will be presented.

50. Surgical Management of Dissecting Aneurysms of the Aorta

Michael E. DeBakey, Walter S. Henly, Denton A. Cooley,

George C. Morris, Jr., E. Stanley Crawford, and Arthur C. Beall, Jr.

Houston, Texas

Certain conceptual changes and new methods of surgical treatment of dissecting aneurysm have grown out of a better understanding of the anatomic and pathologic patterns of the disease during the past decade. These lesions are now classified as follows: (1) Type 1, the intimal tear arises in the ascending aorta and the dissecting process extends distally into the arch for a varying distance. (2) Type 2, the dissecting process is limited to the ascending aorta. Types 1 and 2 are usually associated with aortic valve incompetence. (3) Type 3, the dissecting process arises in the descending thoracic aorta near the origin of the left subclavian artery and extends distally, often into the abdominal aorta. For each of these basic types of dissection appropriate operative procedures have evolved through application of concepts which provide better understanding of the disease. Recent experience based upon these concepts of therapy shows that operative mortality has been reduced to 12 per cent from our previous experience of 26 per cent. Surgical management of all types of dissecting aneurysms is now considered the treatment of choice, and in select instances emergency operation should be performed.

*By invitation