Tuesday Morning, March 30, 1965
8:30
A.M. Scientific Session: THORACIC
SURGERY FORUM
International
Room
15. Motility Disturbances Caused by Esophagitis
Arthur M. Olsen, and Jerry F. Schlegel*,
Rochester, Minn.
Patterns of esophageal motility have been described for
the normal esophagus and for disturbances of function such as achalasia,
diffuse spasm and scleroderma. Recently the identification of hiatal hernia by
pressure determinations has been described. The esophageal motility records of
60 patients with proven esophagitis as demonstrated at esophagoscopy have been
examined. Patients with classical achalasia or diffuse spasm or with clinical
evidence of scleroderma were excluded from the group. Patients with moderate to
severe esophagitis often had evidence of neuromuscular disturbances similar to
those observed in patients with sclerodermal involvement of the esophagus. In
these cases, the esophageal responses to swallowing were feeble and
simultaneous and the gastroesophageal sphincter relaxed poorly. Most of the
patients with mild degrees of esophagitis had normal esophageal motility except
for the evidence of hiatal hernia. Some of these, however, did show early motor
incoordination. It was apparent from our study that esophagitis may produce significant
impairment of esophageal motility, and in the more severe cases this is
probably irreversible. The recognition of disturbed function which may
accompany esophagitis should be of great importance to the surgeon who is
contemplating repair of hiatal hernia.
16. The Experimental Production of Esophageal
Achalasia by Destructive Lesions in the Medulla
Brian Higgs*, F. W. L Kerr*, and F. H. Ellis, Jr.,
Rochester, Minn.
Electrolytic lesions were placed in the motor nuclei of
the vagus nerve of dogs and cats using a stereotaxic technique. Pre- and
postoperative records of esophageal function were obtained using established
manometric, fluoroscopic and cineradiographic techniques. Necropsy studies
performed from one to six weeks after operation have included histologic
studies of the medulla, peripheral vagus nerves and esophagus. The findings to
date suggest that a condition indistinguishable from esophageal achalasia in
man can be produced by focal lesions in the medulla. Postoperative motility
studies show absence of esophageal peristalsis, normal sphincteric pressures
and failure of the inferior esophageal sphincter to relax after swallowing.
There is radiographic evidence of esophageal dilatation and narrowing of the
distal esophageal segment with obstruction. These results provide further
support for the concept that esophageal achalasia is the result of an
extraesophageal vagal lesion.
17. The Use of Intercostal Pedicle Grafts in Esophageal Repair
Lester Bryant*, Lexington, Ky.
Sponsored by Ben Eiseman
Dehiscence of the suture line with fistula formation
and stricture occurs with significant frequency after operations on the
esophagus. In this study, pedicle grafts of intercostal muscle containing the
neurovascular bundle were used to close surgical defects and to reinforce
suture lines in the canine thoracic esophagus. Excision of a two centimeter
segment of the mid-esophagus was performed in twenty animals with end to end
anastomosis using a single layer of sutures spaced at 6 millimeter intervals to
produce deliberate defects in the suture line. In 10 of these, an intercostal
pedicle graft was utilized for circumferential reinforcement of the anastomosis
with 90 per cent survival and no evidence of fistula formation or stricture.
Six of the 10 control dogs died of mediastinitis and two of the survivors
developed esophageal stenosis. In a second group of 10 animals, a surgical
perforation of the thoracic esophagus was repaired after 24 hours delay. Repair
was effected by a pedicle graft in half the animals with one death due to
infection, and mild stenosis of the esophagus in one of the survivors. Four of
the five animals repaired by direct suture only expired with esophago-pleural
fistulae. The results indicate that intercostal grafts may be useful for
closure of traumatic defects, fistulas and anastomoses of the esophagus.
18. Regional Blood Flow in Bronchogenic Carcinoma
Utilizing Radioisotope Scanning
Hurst B. Hatch, Jr.*, William Maxfield*, and John Ochsner,
New Orleans, La.
A new radioisotope scanning procedure was used on 50
patients with primary bronchogenic carcinoma in an attempt to obtain regional
pulmonary blood flow. All patients except those with peripheral lesions smaller
than 2 cm. in diameter showed abnormality in pulmonary blood flow in the
diseased portion of the lung. The material used is I131 labeled
macro-aggregated albumin. The procedure is non-toxic to the patient, does not
require elaborate preparations, and can be performed in a relatively short
period of time. The role that this procedure plays in determining the
operability of the carcinoma, the response to therapy, and the prognosis will
be discussed.
19. Selective Bronchial Artery Catheterization for
Diagnosis and Chemotherapy of Pulmonary Neoplasms
Robert E. Paul, Jr.*, Paul C. Kahn*,
and Harold F. Rheinlander, Boston, Mass.
We would like to present a preliminary report on
selective bronchial arteriography in the human. The methodology of bronchial
arterial catheterization utilizing a retrograde percutaneous femoral arterial
approach will be described. Normal bronchial arterial patterns and
demonstrations of tumor vessels in patients with carcinoma of the lung will be
presented. The preliminary results of acute and chronic bronchial arterial
perfusion with chemotherapeutic agents in patients with advanced carcinoma of
the lung will be reported.
20. The Pattern of Lymphatic Flow During Extracorporeal Circulation
Arthur E. Baue*, Moreye Nusbaum*, George L. Anstadt*,
and William S. Blakemore, Philadelphia, Pa.
The response of the lymphatic circulation to
cardiopulmonary bypass, which could provide information about physiologic
derangements during perfusion, has not been systematically studied. To
determine this, the thoracic duct was cannulated in 55 dogs with lymph content
and flow measured before, during and after bypass. Perfusion rates from 40-90
cc/kg.min. and priming solutions of blood, dextrose-water, dextrose-saline or
dextran were used. Differential flows from various regions and changes in RISA
appearance time and concentration were measured. A consistent pattern of lymph
flow was observed with increases of 300-600% at the beginning of bypass and
then decreasing slowly. At the end of bypass, a further decrease occurred
reaching control levels much later. This did not correlate well with arterial
or venous pressures, perfusion rates, priming solutions or volume changes and
is in contrast to reports that lymph flow decreased or stopped with
"non-pulsatile" perfusion. Red cells and hemoglobin increased during perfusion.
The exaggerated turnover through the lymphatic circulation indicating capillary
membrane exchange and interstitial fluid change may account for some of the
changes described with perfusion such as sequestration, the "homologus blood
syndrome" and post-perfusion volume deficits. The results and significance of
these observations as they relate to the physiology of bypass will be
presented.
21. Hemodynamic Studies of the Importance of Blood Viscosity and
Osmolarity
Robert L. Replogle*, and Robert E. Gross,
Boston, Mass.
Each of 45 closed-chest, splenectomized dogs underwent
the following measurements before and after moderate hypotension was induced by
hemorrhage using the Lamson-Fine technique: cardiac output, renal and carotid
blood flows, left ventricular, pulmonary artery and aortic pressures, serial
blood volumes, serum osmolarity and whole blood and plasma viscosity. The
effects of infusions of low molecular weight dextran, 20% mannitol, 50%
glucose, and packed red cells were observed. Conclusions reached: 1. Hematocrit
changes profoundly influence blood flow, even when the hematocrit remains
within a relatively "normal" range. Increasing the hematocrit from 30% to 60%
results in a 50-100% decrease in cardiac output, carotid and renal blood flow.
Hemodilution results in a marked increase in cardiac output and peripheral
flow. 2. If low molecular weight dextran is infused while hematocrit is kept
constant, no change in cardiac output or peripheral flow is observed, even
though a measurable reduction in plasma viscosity occurs. This evidence
suggests; a) the principal mechanism by which low molecular weight dextran
influences blood flow is by lowering hematocrit; b) the practical importance of
plasma viscosity is minimal. 3. Increasing serum osmolarity by infusion of
hypertonic solutions results in a marked increase in cardiac output and
peripheral blood flow, even when hematocrit remains unchanged.
22. The Distribution of Pulmonary Blood Flow After
Subcla-vian-Pulmonary Anastomosis: An Experimental Study
Lynn Fort III*,
Andrew G. Morrow, George E. Pierce*,
Masahiro Saigusa*, and Joseph S. McLaughlin*,
Bethesda, Md.
When a subclavian-pulmonary anastomosis is made, it is
usually necessary to construct it at a relatively distal site on the pulmonary
artery, and surgeons have speculated as to whether the shunted blood is
directed principally to the lung on the operative side or whether it is equally
apportioned to both lungs. Radioactive microspheres, which could not pass the
pulmonary capillaries, were injected into the circulation of dogs and their
concentration determined in lung homogenates. The distribution of the
microspheres was similar to that of tagged red cells. With a left
subclavian-pulmonary anastomosis, an average of 74% of the shunted blood was
delivered to the left lung and 26% to the right lung. The shunt also changed
the normal distribution of blood ejected into the pulmonary artery from the
right ventricle, 76% being delivered to the right lung and 24% to the left.
Similar effects were noted after rightsided anastomoses, i.e., the shunted
blood preferentially perfused the right lung and the right ventricular output
the left lung. These experimental findings are compared to the altered
hemodynamics which apply in patients with congenital heart disease, and a
method for extending the observations to man is suggested.
23. A New Technique for Replacement of the Aortic Arch
Carlos R. Lombardo*, Antonio L. S. Machado*,
and James R. Jude, Miami, Fla.
Resection of the ascending aorta for aneurysms and
acute dissection has only been accomplished with the use of extra-corporeal
circulation. The morbidity and mortality associated with their removal is
usually the result of severe postoperative hemorrhage and shock secondary to
heparinization. A new technique using a specially designed aortic valve which
can be inserted into the apex of the left ventricle or a catheter with a
ball-valve at its extra-cardiac end is introduced in the left ventricle via the
left atrial appendage and sutured to the decending aorta by a sleeve of woven
teflon. The coronary circulation is maintained by occlusion of the aorta above
the coronary ostia and cerebral circulation by end-to-side anastomosis to the
shunt. Eight animals have had either resection of the ascending aorta and
replacement with a graft or have had simple perfusion of the entire aorta
except the coronary arteries by this method. Hemodynamic studies have revealed
only minimal pressure gradients between the left ventricle and the aorta, no
incidence of arrhythmia and no elevation of pressures in the left atrium
indicating adequate coronary perfusion. All of the animals have survived and
none have shown any evidence of neurological dysfunction.
24. Obstruction of the Coronary Ostia During
Systole by the Aortic Valve Leaflets
R. T. Padula*, R. C. Camishion, and W. F. Ballinger II*,
Philadelphia, Pa.
A series of experiments was designed to demonstrate
that obstruction of the coronary ostia by the aortic valve leaflets occurs
during systole in the intact dog and accounts in part for the diminished
coronary blood flow during this phase of the cardiac cycle. Group I. Coronary
blood flow through the circumflex artery was measured before and after bypass
of the aortic valve - coronary ostia mechanism using systemic-circumflex artery
anastomoses (ten dogs). Group II. The valve leaflets and ostia were operatively
marked and their relative movements observed by cinefluorography (two dogs).
Group III. The functioning valve leaflets and ostia were directly photographed
on motion picture film (five dogs). In group I, the initial sharp decrease in
blood flow normally found during systole was not observed after the valve -
ostia mechanism was bypassed. Thus, systolic blood flow was increased (12%) but
was still less than diastolic flow. Cinefluorograms (group II) and motion
pictures (group III) conclusively demonstrated that the valve leaflets cover
the ostia during early systole. Occlusion of the coronary ostia by aortic valve
leaflets occurs during early systole (as well as increased resistance in the
peripheral coronary arterial bed caused by the contracting myocardium) reducing
coronary blood flow during systole.
25. The Diagnosis of Pericardial Effusions with
Ultrasound: An Experimental and Clinical Study
John A. Waldhausen*, Harvey Feigenbaum*, and Lloyd P. Hyde*,
Indianapolis, Ind.
Sponsored by Harris B Shumacker, Jr.
The differentiation of pericardial effusion from a
large failing heart is not always easy, although essential for proper therapy.
The use of ultrasound offers a simple yet specific technique for the diagnosis
of the effusion. An ultrasonoscope emitting vibrations of above 20,000
cycles/sec, was used. Five dogs had saline introduced through a catheter into
the pericardium. A sonar probe was placed over the sternum and the reflected
echos from the posterior heart wall and pericardium observed. With pericardial
fluid present, 2 widely separated reflected signals were present. Without fluid
the signals fused. Two normal patients showed one signal coming from the region
of the posterior heart wall. In three patients with subsequently proven
pericardial fluid, two signals were recorded from the region of the posterior
heart wall. A number of patients with proven absence of fluid but large hearts,
in contrast, showed only one echo. Limited excursions of the signal reflected
poor myocardial contractility. This method appears accurate and has not shown
any false positive or negative tests. It has no ill effects and is no more
difficult to do than an electrocardiogram. Further studies are in progress.
26. CO2 Flooding of the Chest in Open Heart Surgery: A Potential Hazard
A. Burbank*, T. B. Ferguson, and T. H. Burford,
St. Louis, Mo.
CO2 flooding of the chest during open heart
surgery has been reported to decrease the incidence of cerebral air emboli. If
the quantity of CO2 returned to the heart lung machine through the
cardiotomy suction line is greater than the capacity of the oxygenator to
remove it, then a hypercap-neic acidosis will develop. A model was designed to
simulate the behavior of a patient under cardiopulmonary by-pass and the effect
of CO2 flooding investigated. As predicted, a hypercapneic acidosis
did develop secondary to the CO2 flooding and persisted for ten to
twenty minutes after the CO2 was discontinued. Two nearly identical
clinical cases were then compared, one with and one without CO2
flooding. A hypercapneic acidosis developed in the second case confirming the
experimental result. When CO2 flooding is used, the operating team
should be aware of the potential hazard of hypercapneic acidosis and take steps
to counteract this hazard.
27. Use of the American and Russian Vascular
Staplers for Coronary Artery Anastomoses in Calves
Donald R.
Kahn*, R. F. Mallina*, William S. Wilson*,
and Herbert Sloan, Ann
Arbor, Mich.
In twelve calves, 2.2 to 2.6 millimeter end-to-end
anastomoses were performed with the American stapler between the circumflex
coronary artery and either the internal mammary artery (6 calves) or a vein or
artery bypass graft which was sutured proximally to the subclavian artery (6
calves). Five calves had 3.3 to 4.1 millimeter end-to-side anastomoses with the
Russian stapler between the circumflex coronary artery and a vein or artery
bypass graft either sutured proximally to the subclavian or stapled end-to-side
to the aorta. All stapled anastomoses remained patent. Coronary
cineangiocardiograms obtained from 2 to 5 months after operation demonstrated
patency without narrowing of the anastomoses. The coronary sinus was cannulated
at this time and occlusion of the anastomotic vessel caused a 40 to 50%
decrease in coronary sinus return. Grossly the stapled anastomoses were covered
by a thin, smooth endothelial lining and their diameter had actually increased
with the growing vessel (0.15 mm. per month). All hearts were normal
microscopically. These studies indicate that stapled anastomoses of the
circumflex coronary artery maintain a patency rate far superior to reported
suture techniques and can supply 40 to 50% of the blood flow to the left ventricle.
Evarts
A. Graham Memorial Traveling Fellow, 1963-64. Present address:
Department
of Surgery, Tokyo University School of Medicine, Motofujicho 1 Bunkyo-ku,
Tokyo, Japan.
*By
Invitation
