WEDNESDAY AFTERNOON, APRIL 19, 1967

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

44. Early Esophagogastrostomy in the Treatment of latrogenic Perforation of the Distal Esophagus

Julian Johnson, Cletus W. Schwegman,*

and Horace MacVaugh III,* Philadelphia, Pa.

Iatrogenic perforation of the distal esophagus is most often the result of an attempt to dilate a stricture, remove a foreign body, or pass a feeding tube through an obstructing carcinoma. In the last fifteen years we have operated upon six patients following this complication in our own hospital, starting the operation within six hours of the time of perforation. In all but one it seemed unreasonable to do a simple suture of the perforation since the distal obstruction was still present. The distal esophagus was resected and an esophagogastrostomy was done. One additional patient, who was esophagoscoped in another city, was operated upon at twelve hours. No primary lesion was recognized but a resection and esophagogastrostomy was done. In no patient did postoperative infection occur. One died in the hospital of a coronary occlusion. It is suggested that resection is an acceptable form of treatment for perforation of the lower esophagus when the diagnosis is made early. Sacrifice of the thoracic esophagus as previously described by us (J. Thor. Surg. 52:827, 1956) may be reserved for the patient in whom the diagnosis or treatment of this complication is delayed.

45. Carcinoma Arising in Hiatal Hernia

Orville F. Grimes, and F. Frank Zboralske,* San Francisco, Calif.

During the 20-year period 1946 to 1966, twelve patients with adenocarcinoma of the stomach arising in an esophageal hiatal hernia have been seen at the University of California Medical Center, San Francisco. A study of the case histories of this group of patients indicates that their symptoms were compatible with those usually seen in uncomplicated hiatal hernia. Dysphagia was often attributed to early stricture formation or to the inflammatory edema which accompanies esophagitis. Some patients in the group were aware of slight changes in symptoms, usually a worsening of the dysphagia. Special emphasis is placed upon the frequent difficulty in establishing a correct radiological diagnosis. Repeated x-ray examinations were often obtained before the lesion in the herniated portion of the stomach was visualized. The importance of a careful contrast study of the hiatal hernia is attested to by the fact that the clinical course in most of the patients in this series was poor because of the relatively advanced state of the lesion at the time of its discovery. Several case histories are presented to illustrate the subtle changes in symptomatology which occurred both early and late in the course of their illness. The necessity for a careful symptomatic evaluation and for follow-up radiological examinations in patients who have even slight degrees of dysphagia is paramount.

46. Hiatal Hernia in Infants and Children

Judson G. Randolph, John R. Lilly,* and James E. McClenathan,

Washington, D. C.

Fifty-two infants and children with symptomatic esophageal hiatal hernia have been seen at the Washington Children's Hospital in the past five years. Thirty-five of these patients were under a year of age. Twenty infants were below the third percentile in weight. Fifteen of the 52 patients were hospitalized because of respiratory complications secondary to repeated aspiration; thirteen were anemic from blood loss. A careful esophagram was found to be of prime importance for diagnosis of significant gastric reflux. Esophagoscopy was reserved for those patients who did not respond to conservative therapy, or who bled. Gastric secretory studies in seven newborn infants with hiatal hernia failed to disclose hyperacidity. Standard growth and development curves of sixteen infants demonstrate the striking nutritional deficiency which untreated hiatal hernia can produce in the early months of life. Two-thirds of the patients responded well to conservative treatment. In nineteen patients, surgical correction of the hernia was required; four had associated pyloroplasty, and in one patient, vagotpmy was performed. Esophageal replacement was necessary in only one patient. This study emphasizes the frequency of hiatal hernia in the infant and defines the indications for early corrective surgery in selected patients.

47. Congenital Posterolateral Diaphragmatic Hernia in the Newborn

J. Judson McNamara,* Anoelo J. Eraklis,* and Robert E. Gross,

Boston, Mass.

Congenital posterolateral diaphragmatic hernia is a common cause of death in newborn infants. This condition can be repaired with virtually no mortality in infants and children over one day of age, but carries a great risk for operation in the first 24 hours of life. The literature records fifty-nine infants less than 24 hours of age requiring diaphragmatic hernia repair; the mortality rate was 56%. One hundred and forty-two cases of congenital diaphragmatic hernia operated on at Children's Hospital Medical Center since 1940 were reviewed. Ninety of these patients were over twenty-four hours old. The mortality was 5% (in the past seventeen years, thirty-seven patients have been operated on with no deaths). Fifty-two patients were less than twenty-four hours of age at the time of surgery. Twenty-three of these died (44% mortality). Further examining this group, it was seen that of thirty-two newborn infants operated on prior to 1960, seventeen expired (mortality 53%) but since 1960, of twenty infants, only six have died (30% mortality). Comparison between the groups of patients prior to 1960 and since 1960 reveals several changes in management which appear responsible for the improved survival of these critically-ill newborn infants. These changes are discussed and the presently employed method of management is described.

48. The Superiority of the Glenn Operation for Tricuspid Atresia in Infancy and Childhood

W. Sterling Edwards, and L. M. Bargeron, Jr.,*

Birmingham, Ala.

A systemic pulmonary artery shunt which imposes additional strain on the single (left) ventricle is usually performed for infants with tricuspid atresia because of the high mortality reported from a superior caval-right pulmonary shunt in the first year of life. Thirty-one infants and children have had the Glenn operation performed for tricuspid atresia over the past six years. In the first eleven patients the azygous vein was ligated and postoperative fluids were given according to the usual formula for infants and children. There were five deaths, a 45% mortality, and death seemed to occur from cerebral edema or hypovolemic shock. The last twenty consecutive patients have had the azygous vein left open to decompress the superior vena cava for 5-10 days, after which the azygous is occluded by tightening a loop ligature previously placed around the azygous and brought out to a subcutaneous button. Large volumes of fluid have been required to replace fluid lost as edema of the upper body. Fifteen of these patients have been less than 18 months of age, two died (13%). All the older children surveyed. Marked improvement in cyanosis and exercise tolerance have been maintained. The Glenn operation seems the operation of choice for tricuspid atresia at any age.

49. Correction of the Younger Tetralogy

A. R. C. Dobell, and E. J. P. Charrette,* Montreal, Quebec.

In our experience the mortality rate following correction of the tetralogy of Fallot has been tripled when the operation included detaching a previously formed aorto-pulmonary shunt. For this reason and with increasing confidence in our ability to correct the lesion, we have lowered the minimal size of patients accepted for correction. We have now operated upon 23 children between 14 months and 5 years of age. Initially, this series consisted of only those children in whom surgery was necessitated by severe spells, high hemoglobin and deep cyanosis. Recently, less severely ill younger children in whom surgery might have been delayed have been operated upon electively. Repair has been carried out through a transverse ventriculotomy in a bloodless, still field. Emphasis has been placed on mobilizing the crista supraventricularis medially and laterally, and on retracting it posteriorly with a prosthetic patch used to close the ventricular septal defect. Twenty-three younger children have undergone correction with one operative death. A second child died several months after operation with dilatation and fibrosis of the right ventricle, possibly caused by right coronary air embolism during the correction.

50. Surgical Treatment of Cardiac Defects Associated with Variations in Cardiac Position

Donal M. Billig,* Grady L. Hallman, Robert D. Bloodwell,*

and Denton A. Cooley, Houston, Texas.

Repair of congenital cardiac defects may be made more difficult by the presence of positional anomalies such as dextrocardia, dextroversipn and levocardia. Thirty-one patients with cardiac lesions and variations in cardiac position were operated upon. Thirteen patients had mirror image dextrocardia and 2 patients had isolated levocardia with abdominal situs inversus. Ten patients had cardiac dextroversion, and 6 patients had abdominal situs inversus with cardiac levoversion. In the 13 patients with mirror image dextrocardia, 8 had successful corrective operations and 5 had successful palliative procedures for a variety of cardiac defects and all survived. The two patients with isolated levocardia had successful closure of ostium secundum atrial septal defects. In only one of six patients with levoversion was corrective surgery possible. The remainder had palliative operations for uncorrectable lesions. Two of these expired in the early postoperative period. The 10 patients with dextroversion underwent palliative operations and four expired. The results indicate the serious nature of lesions associated with dextroversion and levoversion, as opposed to the usually correctable defects in the group with mirror image rotations. This presentation will review anatomic features of cardiac positional anomalies as they influence the repair of congenital cardiovascular defects.

*By invitation