Wednesday Afternoon, May 18, 1966

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

44. Gastroesophageal Reflux and Hiatus Hernia: Complications and Therapy

Harold G. Urschel, and Donald L. Paulson, Dallas, Texas

Although gastroesophageal reflux has been associated with esophageal hiatal diaphragmatic hernia, its true significance has not been fully appreciated until recently. Of 1148 patients with esophageal hiatal hernia or gastroesophageal reflux without hernia, 15 percent were recognized as having respiratory symptoms prior to 1961 in contrast to 50 percent since that date. Symptoms include cough, hoarseness, bronchitis, asthma, and pneumonitis. Gastroesophageal reflux was documented with esophagoscopy and esophageal cine fluorography. Patients with gastroesophageal and pulmonary complications secondary to reflux with, or without, elevated gastric acids were managed by reconstruction of the gastroesophageal angle and hernia repair. In those with associated duodenal or gastric ulcers and elevated acids vagotomy and pyloroplasty were added. Longitudinal stenoses were treated by dilatation, reconstruction of the gastroesophageal angle and hernia repair except where esophageal shortening necessitated colon interposition. Annular strictures were treated through a transthoracic gastrotomy by circumferential mucosal resection and anastomosis, gastroesophageal angle reconstruction and hernia repair. Comparison of 436 patients operated upon by modified Allison procedures with 227 patients undergoing "Belsey" operations indicates a 10 percent hernia recurrence, and a 25 percent persistence of gastroesophageal reflux in the former group, and 2 percent hernia recurrence and less than 10 percent reflux in the latter.

45. Surgical Management of Esophageal Reflux and Hiatus Hernia: Long Term Results with 1030 Patients

David B. Skinner*, Boston, Mass., and Ronald Belsey*,

Bristol, England

Sponsored by Paul S. Russell

One thousand and thirty patients, including 119 children, required surgical treatment for esophageal reflux and hiatus hernia at the Thoracic Surgery Unit, Bristol, England, between 1949 and 1962. Symptoms, esophagoscopic and radiographic findings, indications for surgery, operative management, and results have been reviewed. Long term follow-up has been obtained in 97%. Post-operative barium swallows were obtained in all patients, and have been repeated during follow-up in 57%. In this series, the standard hiatus hernia repair has been a technique developed at Frenchay Hospital, which creates a segment of intra-abdominal esophagus held in place by an exaggerated esophago-gastric angle. This technique will be described. Studies of the motor function and pH gradient of the cardia before and after hiatus hernia repair support the physiological effectiveness of this method. Low mortality, complication and long term recurrence rates have been encouraging. Factors contributing to recurrences have been identified. When hiatus hernia repair has not been possible, other techniques such as left colon interposition or esophagogastrectomy have been employed. A review of this experience suggests an overall approach to the management of esophageal reflux and hiatus hernia.

46. Functional Evaluation of Childhood Esophageal Replacement

H. Biemann Othersen, Jr.*, Charleston, S.C., and

H. William Clatworthy, Jr., Columbus, Ohio

In children, which technique of total esophageal replacement functions best? At present, the colon appears to be the substitute of choice. However, other questions must be answered. Should the interposed colon be: Right, transverse, or left colon? Iso- or anti-peristaltic? Retrosternal or intra-pleural? In order to answer these questions concerning technique and to evaluate mechanical function of the transplant and its effects on somatic growth, this study was undertaken. From 1960 to 1965 a total of eleven children have had total esophageal replacement for atresia or caustic stricture at the Children's Hospital, Columbus, Ohio. All patients were evaluated clinically and with detailed cinefluoroscopy. Evidence will be presented for the following conclusions: 1) A single stage colonic interposition is preferable. 2) The interposition operation should be delayed until the child is ambulatory and has been taught to chew and eat. 3) There is no discernable difference in function between right and left colonic segments and between anti- and iso-peristaltic arrangements. Small bowel segments do retain peristalsis, but of a segmenting rather than propulsive type. 4) The interposed colon acts not as an esophageal substitute but as a conduit only. Gravity, not peristalsis, governs the flow of ingested material.

47. Post-Operative Changes in Regional Pulmonary Blood Flow

Lester R. Bryant*, Lexington, Ky., Frank C. Spencer,

New York, N.Y., Robert H. Greenlaw*, Ponosiri Prathnadi*,

and John Bowlin*, Lexington, Ky.

Lung scintiscans with macroaggregated radioalbumin were performed in 80 patients on the 1st or 2nd, and the 7th day following thoracic (25 cases) and abdominal (55 cases) operations to detect pulmonary emboli and changes in distribution of pulmonary blood flow. Chest roentgenograms, arterial blood gas studies and pulmonary arteriograms were made at the same time. The initial scintiscan was abnormal in 45 patients (56%) but returned to normal by the 7th post-operative day in 32. The principal changes were: 1) wedge-shaped defects, simulating emboli; 2) absence of blood flow in the lung periphery, and, 3) decreased blood flow to the lung bases. These changes were usually associated with a normal roentgenogram but with mild decreases in pO₂ (50-63 mm.Hg) and oxygen saturation (86-92%). The pulmonary arteriograms demonstrated small emboli in only 2 patients, but clinical evidence of atelectasis or pneumonia occurred in 12 patients with abnormal scintiscans and in only 2 patients with normal regional blood flow. The frequency of unsuspected transient changes in regional pulmonary blood flow limits the diagnosis of pulmonary emboli by scintiscanning alone, and suggests that post-operative atelectasis may be preceded by changes in regional blood flow.

48. Pulmonary Embolectomy. Eighteen Months' Experience at Brompton Hospital

M. Paneth*†, London, England

Sponsored by John W. Kirklin

An account will be given of emergency pulmonary embolectomy with cardio-pulmonary bypass. The clinical material has been gathered from a number of hospitals in and around London and consists of more than 12 cases. The factors affecting a successful outcome will be analysed. The importance of the history, physical signs and of simple investigations will be pin-pointed leading to an accurate clinical diagnosis. Physiological data will be presented, both experimental and clinical, relating to pulmonary embolism with particular reference to its effect on the function of the right ventricle. Late results of untreated massive pulmonary embolism with survival will be shown and a surgical approach to these cases will be indicated.

49. Coronary Artery: Bight Heart Fistulas

Rodman E. Taber, Henry H. Gale*, and Conrad R. Lam, Detroit, Mich.

Congenital fistulas between a coronary artery and the right side of the heart may present physical findings which are difficult to differentiate from those of patent ductus, aorto-ventricular fistula or aortic insufficiency. Right-sided cardiac catheterization will establish the presence of a left-to-right shunt in these patients, but coronary arteriography must be relied upon to identify the exact site of the fistula and permit closure with minimal disturbance of the normal coronary circulation. Four patients successfully underwent closure of fistulas between the right coronary artery and right side of the heart. The shunt was between the sinus node branch of the right coronary artery and the right atrium in three patients. An anterior branch of the right coronary artery and the right ventricle were involved in the fourth patient. The fistulas were divided in three patients and over-sewn in one. Although electrocardiographic signs of myocardial ischemia were not uncommon in the immediate postoperative period, all four have recovered and are free of cardiac murmurs.

50. Direct Coronary Artery Surgery with Endarterotomy and Patch Craft Reconstruction: Clinical Application and Technical Considerations

Donald B. Effler, Laurence K. Groves, Ernesto Suarez*, and

Rene G. Favaloro*, Cleveland, Ohio

Between January 1962 and December 15, 1965, 51 operations were performed in the Cleveland Clinic Hospital for direct relief of coronary artery obstruction. Eleven deaths occurred at or immediately after operation; each death is attributable to induced myocardial infarction and represents surgical failure. Nine of the 11 deaths occurred in the 17 operations on the left coronary artery. Indications for the direct approach are greater than anticipated. Our initial experience includes endarterectomy

*By Invitation

†Evarts A. Graham Memorial Traveling Fellow, 1956-57