International Ballroom Center

47. Prognostic Significance of Tumor Doubling Time in Evaluating Operability in Pulmonary Metastatic Disease

Donald L. Morton,* William L. Joseph,* and Paul C. Adkins

Washington, D. C.

Although arbitrary criteria have been suggested for evaluating operability in metastatic pulmonary disease, the results after resection based on these criteria are often disappointing. A more uniform and precise method is needed in predicting survival. Tumor doubling time (TDT) was measured in 92 patients with pulmonary metastatic lesions after control of their primary. Sixty-eight had no treatment for their pulmonary spread, while 24 had some type of resection. In 58 individuals whose TDT was less than 20 days, the median interval between resection of the primary and the appearance of pulmonary metastasis was 4.5 months; 68% survived 6 months, 9%, one year. In the remaining patients with a TDT greater than 20 days the median interval between the primary lesion and onset of metastasis was 1.2 years; 90% were alive at 6 months, 76% at one year. Those patients with a TDT greater than 40 days had an unusually good result following pulmonary resection even when bilateral thoracotomy was necessary. Tumor doubling time appears to be an accurate method for quantitation of tumor growth and an important criteria for evaluating operability. This study suggests a more aggressive approach should be used in patients with metastatic pulmonary disease having prolonged doubling times.

48. Primary Sarcoma of Lung

Nael martini,* Steven I. Hajdu,* and Edward J. Beattie, Jr,

New York, N.Y.

From 1926 to 1968 there were 42 primary sarcomas of the lung seen at the Memorial Hospital. In this interval 5714 new lung tumors were seen, indicating the sarcoma to be 0.74% incidence. Twenty patients had lymphoma confined to the lung and 22 had a variety of soft tissue sarcomas (leiomyosarcoma, rhabdomyosarcoma, spindle cell sarcoma and angiosarcoma) also confined to the lung. No patient was lost to follow-up. Ten of 22 lymphomas had no recurrence of disease after treatment. Seven of these were free of disease for 6 ½ to 27 years. Three of seven leiomyosarcomas were well for 14, 16 and 20 years respectively, but none of 13 other soft tissue sarcomas remained free of disease. Review of this material is interpreted to show: 1. One cannot be certain from limited histologic material as to the primary site. The correct diagnosis is confirmed by thorough study of the patient and careful observation of his course. 2. In lymphoma the prognosis is not accurately predicted by the histologic examination alone. 3. In contrast, the histologic cell type of soft tissue sarcoma can be recognized and is of the utmost importance for prognosis. 4. Complete surgical excision is the treatment of choice.

49. Primary Pulmonary Cryptococcosis

Charles R. Hatcher, Jr., Jagjit S. Sehdeva,* Victor Schulze,*

William D Logan, Jr., P. N. Symbas, and Osler A. Abbott,

Atlanta, Ga.

Human infection with Cryptococcus Neoformans, once thought to be a rare disease, is being recognized and treated with increasing frequency. Although the portal of entry is most likely the lungs, the isolated pulmonary forms of the disease account for only 10% of proven cases. The best opportunity for rapid and permanent cure of cryptococcal infection lies in the diagnosis and treatment of the primary infection of the lungs. Experience with twenty-four cases of primary pulmonary cryptococcosis diagnosed and treated at Emory University between 1952 and 1969 forms the basis of this report. Epidermiology, clinical and laboratory diagnosis, differential diagnosis, and results of medical and surgical treatment are presented. A high index of suspicion and diligent diagnostic efforts are required to make the diagnosis of cryptococcal infection without thoracptomy. Local and disseminated forms of pulmonary infection required a variety of surgical procedures. Amphotericin B is of value in the management of certain forms of infection and in prevention of dissemination. With an aggressive medical-surgical approach, pulmonary cryptococcosis was controlled in all cases with ultimate survival of these patients.

50. Gastroplasty: An Operation for the Management of Peptic Stricture with Acquired Short Esophagus

F. G. Pearson, B. Lanoer,* and R. D. Henderson,*

Toronto, Ontario, Canada

The optimal correction of peptic stricture with acquired short esophagus requires restoration of normal swallowing and prevention of gastro-esophageal reflux. Sufficient esophageal shortening precludes control of reflux by standard techniques of hernia repair. Esophageal resection and interposition of bowel is accompanied by significant mortality and morbidity, and in our experience a normal swallowing mechanism is not usually achieved. In 1957 Collis described the operation of gastroplasty, in which normal esophageal length is restored by creating a tube from lesser curve of stomach in continuity with distal esophagus. Effective hernia repair is now possible, and further reflux prevented. Esophagitis resolves and stricture is well managed by dilatation. During the past six years at Toronto General Hospital, 16 patients with peptic stricture and acquired short esophagus were managed by gastroplasty combined with a Belsey hiatus hernia repair. Results of treatment were assessed by history, cine-barium esophagograms, esophagoscopy and esophageal manometry. There was no operative mortality. No patient has symptomatic or radiologically demonstrable reflux, and the esophagogastric "valve mechanism" was competent by manometric analysis. Esophagitis and stricture resolved to the extent that 12 of 16 patients now experience normal swallowing and require no further dilatation. 4 recent patients still require postoperative dilatation.

51. Correction of Heart Disease in Infancy Utilizing Deep Hypothermia and Total Circulatory Arrest

D. H. Dillard, Hitoshi Mohri,* and K. A. Merendino,

Seattle, Wash.

Correction of cardiac lesions in infancy results in a greater salvage of life and reduces emotional and financial stress for the family. During the past four years 14 critically ill infants with complex cardiac lesions were totally corrected utilizing surface induced deep hypothermia to 17° to 20°C with total circulatory arrest for 20 to 57 minutes. Management is simplified by avoidance of perfusion and heparin. Infants ranged from 3 days to 19 months and 2.2 to 8.8 kilograms. A total of 30 patients were operated, 25 of which were potentially correctable. Of these 6 of 7 patients with transposition of the great arteries (86%) and 5 of 8 patients with total anomalous pulmonary venous drainage (62%) were salvaged. Other lesions treated successfully included pulmonary atresia and ventricular septal defects. There were no failures and no nervous system damage thought to be related to the technic of hypothermia. All corrected patients resuscitated without ventricular fibrillation. We believe that the procedure of choice in infants dying with correctable lesions is an attempt at total correction under surface hypothermia. The use of a surgical palliative procedure requiring a second corrective procedure at a later date is often needleess and inappropriate.

52. Surgical Correction of Congenital Pulmonary Atresia with Ventricular Septal Defect

Nicholas T. Kouchoukos,* Alberto Barcia,*

Lionel M. Bargeron,* and John W. Kirklin,

Birmingham, Ala.

Seven patients with congenital pulmonary atresia and ventricular septal defect have been operated upon by us since April, 1964. Five patients have survived. In this entity, the infundibulum of the right ventricle is absent or severely underdeveloped, there is no connection between right ventricle and pulmonary artery, and the ventricular septal defect is large. The pulmonary artery may arise from aorta (truncus arteriosus) from ductus arteriosus (pseudotruncus) or it may be absent with right and left pulmonary arteries (or simply collateral vessels) arising directly from the aorta. The operation consists of closure of the ventricular septal defect, interruption of the major aortico-pulmonary connections, and interposition of a conduit between the right ventricle and pulmonary arteries. In the first four patients, the conduit was a tube of pericardium or woven Teflon without a valve. In the last three patients, it was an aortic homograft with its valve or a Dacron tube with an aortic homograft valve within it. The latter is presently preferred. Naturally occurring or surgically created aortico-pulmonary anastomoses may make operation difficult. Precise angiographic definition of the anatomy is essential. Late results have been excellent except in one early case in which the conduit did not contain a valve.

53. Pulmonary Atresia with Intact Ventricular Septum

Frederick O. Bowman, Jr., James R. Malm, Constance J. Hayes,*

Welton M. Gersony,* and Kent Ellis,* New York, N.Y.

In the neonatal age, results of surgery for pulmonary atresia with intact ventricular septum have been generally poor up to the present time. Pulmonic valvulotomy has produced only occasional success. More rewarding results have been obtained by systemic-pulmonary artery shunts to increase pulmonary blood flow. Recently, an operative approach has been used which allows both pulmonic valvulotomy for right ventricular decompression and an aortic-pulmonary artery (Waterston) shunt to increase pulmonary flow. In the past five years, 15 patients under two weeks of age with pulmonary atresia and intact ventricular septum have been admitted to Columbia-Presbyterian Medical Center. Surgery was performed on 12 patients with 7 survivors. Six of 7 patients on whom a shunt was performed, with or without valvulotomy, survived. The single patient who survived valvulotomy alone required a shunt before one year of age. Late total correction was attempted in 2 patients with one survivor. The variable anatomy encountered should influence the operation performed. Abnormal right ventricular function and abnormal tricuspid valvular function must be considered in addition to the pulmonary valve atresia.

54. Repair of Transposition of Great Vessels by Transposition of Venous Return: Surgical Considerations and Results of Operation

Gordon K. Danielson, Douglas D. Mair,* Patrick A. Ongley,*

Robert B. Wallace, and Dwight C. McGoon, Rochester, Minn.

Sixty-nine patients underwent correction of transposition of the great vessels (TGV) by venous transposition (Mustard procedure). Ages ranged from 8 months to 19 years (median 4 years), and 29 had prior palliative operations. Operative mortality was 12% to 25 patients without ventricular septal defect (VSD), 54% for 28 patients with large VSD, and 40% for 15 patients with large VSD and severe pulmonic stenosis (PS). One patient with severe PS and intact ventricular septum also died. In patients without severe PS, absolute pulmonary vascular resistance (APVR) and pulmonary vein-to-artery oxygen content difference (PVAD) were useful criteria for determining operability. Twenty-six of 38 patients (68%) with an APVR of 10 units or less and a PVAD of less than 2.4 vol % survived operation, whereas all patients with higher values died. Three late deaths occurred; 95% of the survivors are clinically well. These data indicate that TGV without PS can be repaired satisfactorily in patients with or without VSD if the above criteria of operability are met. Patients wth VSD and severe sub-valvular PS are best treated by diversion of the left ventricle to the aorta and aortic homograft reconstruction of the right ventricular outflow tract.

*By Invitation