WEDNESDAY AFTERNOON, APRIL 28, 1971

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

45. Long-term Results of the Mark IV Operation for Hiatal Hernia and Analyses of Recurrences and their Treatment

Mark B. Orringer,* and David B. Skinner, Baltimore, Maryland

and Ronald H. R. Belsey, Bristol, England

From 1955 to 1965 approximately 900 Mark IV operations for hiatal hernia and/or gastroesophageal reflux were performed at Frenchay Hospital, Bristol, England. Followup evaluations of clinical results, radiographic, and endoscopic findings in patients operated upon more than five years previously revealed recurrences of hiatal hernia, gastroesophageal reflux, or both in approximately 12% of patients followed more than five years, 14% in patients followed more than seven years, and 18% in patients followed more than ten years. Causes of recurrences were found to be due to attempting reduction of the hernia in the presence of severe esophagitis and esophageal shortening, diaphragmatic or esophageal sutures cutting through, or inadequate operative reconstruction. Recurrences were further related to age of the patient and experience of the operator. Details of management for the recurrent reflux problem will be discussed including indications for repeat Mark IV operations, pyloroplasty, a resection and colon interposition. Results of treatment for recurrent hiatal hernia will be presented.

46. The Nature and Surgical Treatment of Lower Esophageal Ring (Schatzki's Ring)

Conrad R. Lam, Rodman E. Taber and Eduardo Arciniegas,*

Detroit, Michigan

In 1953, Schatzki and Gary published a paper entitled "Dysphagia due to a diaphragm-like localized narrowing in the lower esophagus" ("lower esophageal ring"), and the description was so good that the senior author's name it commonly used to describe the lesion. In 1955, Bugden and Delmonico reported two cases cured by removing wedges from the diaphragm through an esophagotc-my. In principle, this operation appears logical, but it has not been universally adopted. The lesion has been called a "semantic and surgical enigma" in the surgical literature, with the suggestion that dilatation is an acceptable form of treatment. We have operated on 18 patients with symptomatic Schatzki's with hiatus hernia. The ring has been excised or eliminted by radial cuts through gastrotomy before reduction of the hernia. We were convinced that any attempt to dilate or rupture the ring by endoscopic methods would be unsatisfactory. A case of rupture of the esophagus after such an attempt is being treated for mediastinitis and empyema. The patients treated by direct approach have remained asymptomatic. Histologic study of the excised portions of the ring invariably showed esophageal mucosa on one side and gastric mucosa on the other.

47. Management of Carcinoma of Cervical Esophagus

Walter J. Burdette and Richard H. Jesse, Jr.,* Houston, Texas

The outlook for carcinoma of the cervical esophagus was found to be more favorable than for carcinoma of the thoracic esophagus among 507 cases of the esophageal carcinoma seen at the M. D. Anderson Hospital Principles found useful in management of this disease are careful preoperative evaluation, radical resection of the cervical lesion and surrounding tissues involved, repair by interposition of ileocolon, and use of irradiation therapy when indicated. The segment of bowel found most useful for interposition has been terminal ileum attached to ascending and right half of transverse colon with pharyngoileal and cologastric anastomoses. Epiglottis can be used as a portion of die anastomosis in the neck. Very careful approximation of pharynx and ileum, testing of suture line with hydrostatic pressure, and use of a broad cuff prevents an annoying leak which otherwise occurs fairly frequently. Limitations imposed by invasion of contiguous organs is greater within the thoracic cavity and possibly explains the more favorable prognosis in carcinoma of the cervical esophagus. The experience with specific cases will be utilized to illustrate problems and procedures characteristic of the methods adopted for managing a very difficult problem.

48. Implications of the Urokinase Study Concerning Surgical Treatment of Pulmonary Embolism

Richard D. Sautter, William O. Myers,* and

Frederick J. Wenzel,* Marshfield, Wisconsin

In a randomized national cooperative trial, urokinase with subsequent heparin therapy, when compared with heparin therapy alone, significantly accelerated the resolution rate of pulmonary thromboembolism at 24 hours. Patients were separated into four categories (I-S, I-M, II-S, II-M) based on the severity and massivity of their pulmonary embolism. In the series of 160 patients, there were 11 who had massive pulmonary embolism with shock (II-M). In this group, there were only two deaths for a two week fatality rate of 18%. Six patients in this group received urokinase and five received heparin only. During the trial, the mortality rate in 11 patients undergoing pulmonary embolectomy at the participating institutions was 73%. It appears that pulmonary embolectomy is a procedure which should have a very limited application. Consideration has been given to the use of lytic therapy in those patients usually recommended for caval Ugation. In light of the recurrence rate for the two groups of patients, at present this cannot be recommended. Comparison of the hemodynamic data, pulmonary scans and arteriograms of the patients treated with urokinase versus those treated with heparin will be presented. Complications of lytic therapy will also be reviewed.

49. Open Heart Surgery Using Deep Hypothermia: The Development and Current Method Using a No Blood, No Oxygenator Technique for Open Heart Surgery

J S. Bailey,* C. E. Drew,* P. A. Cullum,* R. Lea,*

M. Sabapathy,* and D. Patchett,* London, England

Sponsored by James A. Key

Since 1959, 841 cases of mixed pathology have been operated on by open heart techniques at St. George's and Westminster Hospitals in London using modifications of the technique first described by Drew. The modifications of these techniques are described, together with a report on 100 consecutive recent cases studied prospectively. There were 36 cases of acquired heart disease and 64 cases of congenital heart disease. The over-all mortality of 13% occurred predominantly in the acquired cases. The results suggest the value of this technique, particularly for use in very young children. Advantages in the technique will be outlined which would recommend its use as an alternative to standard cardiopulmonary bypass, particularly for early total correction of lethal lesions in the neo-natal period.

50. Reconstruction of the Right Ventricular Outlet with a Fascia Lata Composite Graft

Marian I. Ionescu,* and Geoffrey H. Wooler,* Leeds, England

Sponsored by Frank Gerbode

For the complete correction of congenital cardiac abnormalities with hypo-plastic or absent right ventricular outlet, a technique of making a composite fascia lata graft has been developed. The graft comprises a conduit for right ventricular outflow tract and pulmonary artery reconstruction, and an inner three cusp valve which provides the conduit with a one-way flow mechanism. The technique of preparing and inserting these grafts is described. Since November 1969 the composite graft has been used in 23 patients. There have been 16 patients with Pallet's tetralogy, 2 with double outlet right ventricle, one with corrected transposition and V.S.D., one with corrected transposition and absent ventricular septum, one with truncus arteriosus type II, one with Fallot's trilogy and one with single ventricle and mitral atresia. All 23 had had pulmonary atresia or hypoplasia and 16 had had previous shunt procedures. There have been 4 hospital deaths. Early results have been very good. No late deaths or clinically detectable complications have occurred. Only 4 patients have had post-operative haemo-dynamic and angle-graphic investigations performed and these show excellent results. The follow-up is too short (5 to 12 months) to draw any conclusions concerning the advantages and drawbacks of this method.

51. The Mustard Operation as a Palliative Procedure

George G. Lindesmith, Quentin R. Stiles,* Bernard L. Tucker,*

Marian E. Gallaher,* Robert E. Stanton,* and

Bert W. Meyer, Los Angeles, California

Our current series of corrective operations on patients who had transposition of the great vessels with favorable anatomy and physiology for total correction now includes thirty cases. There has been only one death in this group and the clinical improvement in the survivors has been startling. The ease with which this operation can be performed upon these favorable candidates and the satisfactory low mortality rate has prompted us to use this procedure in less favorable circumstances. We have had seven patients in this category. The group of patients with transposition of the great vessels associated with severe pulmonary hypertension, usually with ventricular septal defect, has been of particular interest. The Mustard operation converts the cardiopulmonary physiology in these patients to one more favorable for long term survival. The arterial oxygen saturation and the clinical performance of these patients have shown marked improvement. We also have used the Mustard operation for patients whose defects made the risk of total correction seem prohibitive. On the basis of this experience we believe that the Mustard operation is a satisfactory palliative procedure.

*By Invitation