2:00 P.M. ScientificSession

Ballroom

9. Pharyngoesophageal Dysphagia and RecurrentLaryngeal Nerve Palsy

ROBERT D. HENDERSON,* ANDREW BOSZKO,*

JOHN DESLAURIERS,* and A. W. PETERvanNOSTRAND,*

Toronto, Ontario, Canada

Sponsored by F. G. Pearson, Toronto,Ontario, Canada

Recurrent laryngeal nerve palsy results in vocal cord paralysis. In agroup of 18 patients with palsy, it was noted that 14 of these patients, inaddition, developed the symptoms of pharyngoesophageal dysphagia. Thesepatients had the sensation of sticking to liquids or solids at thepharyngoesophageal junctions and many developed a cough with swallowing,secondary to aspiration of food. Fifteen of 18 patients had bronchogeniccarcinoma with the recurrent nerve palsy being secondary to carcinoma orfollowing deliberate resection of the nerve at lung resection. In 1 patient theaetiology of recurrent nerve palsy was considered to be viral and in 2 it wassecondary to thyroid surgery.

The obstruction produced aspiration and lung infection in 3 cases andpharyngoesophageal myotomy was necessary to correct the swallowing problem. Inall 3 cases, the dysphagia was corrected. These patients have been studied bybarium swallow, esophageal motility and esophagoscopy.

Five autopsy specimens have been examined and, in each, branches of therecurrent nerve were traced to the cricopharyngeal muscle. The significance ofthis symptom, in producing respiratory infection in pneumonectomised patients,is demonstrated and cricopharyngeal myotomy has been shown to correct theproblem.

10. A Simple Physiological Diaphragmatic HerniaRepair

VICTOR H. KAUNITZ, Kenmore, N.Y.,

LEONARD A. KATZ,* DAVID VASTOLA,* and

LOUIS MAAS,* Buffalo, New York

Because of the unacceptably high recurrence of current diaphragmatichernia repairs, utilizing the fundal plication principle (10 to 15% in Belseyoperations), a different technique of repair has been developed. An attempt ismade to restore normal anatomy, and, thereby, normal physiology, by placingholding sutures in strong gasteric wall, immediately below thecardio-esophageal junction, and securing these sutures to tendon of diaphragm.The lower esophageal sphincter (LES), is, thereby, repositioned within theperitoneal cavity, without creating any unnecessary flap valve mechanism. Byusing the strong gastric wall, rather than the weak esophagus, for the basicrepair sutures, it is hoped that recurrence will be greatly minimized. To date,with the longest follow up 2 � years, there has been no recurrence in 60patients.

The effectiveness of this simple technique in preventing gastric refluxhas been confirmed clinically, and by laboratory data. All patients have hadcomplete subsidance of reflux symptoms. Pre-operative, and 3 month post-operativemotility and reflux studies were done in a consecutive group of 23 patients.Lower esophageal sphincter (LES) activity, esophageal peristalsis, acid refluxand acid clearing were measured. Sixteen of 23 patients (70%) had low (10mms.Hg. or less) LES pressure. Following surgery, 92% of LES pressures rose. Meanpre-operative LES pressure was 6.6 mm. Hg.; mean post-operative pressure was12.9 mm. Hg. (p <.005). Sixty-five per cent of 20 patients measuredpre-operatively, had gastric reflux; post-opera lively 90% showed no reflux.

11. The Use of Circular Myotomy to FacilitateResection and End-to-End Anastomosis of the Esophagus: An Experimental Study

JESSADA MUANGSOMBUT,* JOHN R. HANKINS,*

and JOSEPH S. McLAUGHLIN, Baltimore,Maryland

Segmental resection of the thoracic esophagus with end to end anastomosiscarries a lower mortality rate than esophagogastrostomy or colon interposition.However, if more than a few centimeters are resected, the anastomosis failsbecause of tension. Presented is an experimental study in which circularmyotomy was utilized to reduce tension and thereby increase the amount ofesophagus which could be resected successfully.

Sixteen dogs were first subjected to end to end anastomosis withoutmyotomy after resection of segments varying from 4 to 7 cm. in length andcomprising 20 to 40% of the esophagus. Of 9 animals in whom less than a thirdof the esophagus was resected, 6 survived. However, of 7 animals in whom morethan 33% of the esophagus was resected, only 3 survived.

Initial attempts at circular myotomy performed 3 cm. proximal to theanastomosis after resection of 40 to 50% of the esophagus failed because ofischemia leading to anastomotic breakdown. Latex injection studies demonstratedthat the myotomy interrupted important vessels running longitudinally in thedeeper layers of the muscularis. Subsequently, it was found that partialmyotomy afforded just as great a reduction in tension without compromising theblood supply. Partial circular myotomy permitted successful anastomosis in 8 of10 animals in whom 45 to 55% of the esophagus was resected.

It is concluded that partial circular esophageal myotomy affords areduction in tension without interruption of blood supply and thus permitssuccessful anastomosis after resection of much longer segments than wouldotherwise be possible.

12. The Value of Resection in Tumors Involving theChest Wall

RALPH J. BURNARD,* NAEL MARTINI,*

and EDWARD J. BEATTIE, JR., New York,N.Y.

68 cases of chest wall resection for malignant tumors are reviewed. Thesecases cover the period 1962 through 1972. The patients ranged in age from 11 to76 years and included 43 males and 25 females. 50% of the patients presentedwith local symptoms and 30% exhibited a visible or palpable mass. Radiographicexamination revealed soft tissue density in 65% and bony erosion in 55%.

Histologic types consisted of 30 primary lung carcinomas, 6 metastaticcarcinomas, and 32 primary sarcomas.

The resected specimen generally included 3 to 4 ribs and produced a chestwall defect of approximately 125 cm^. Skeletal reconstruction was accomplishedwith marlex mesh in 46 cases, ox fascia in 7 and by other methods in 3. Noskeletal reconstruction was used in 12 cases. The majority of the casesrequired little or no major cutaneous reconstruction.

The operative mortality was 10%. 50% of the patients developed some formof cardiopulmonary complications. Of these, 60% were pulmonary, 30% infectious,and 10% cardiovascular. The relationship between preoperative radiation therapyand surgery is discussed. 20 patients required tracheostomy for varying periodsof time, only 4 of which were considered emergencies. 15 patients requiredrespiratory support for 24 hours or more. The median hospital stay was 16 dayswith a range of 8 to 108 days.

24 patients survived for two or more years. The value of chest wallresection is discussed relative to morbidity, mortality, palliation andsurvival following the procedure. Observations on methods of skeletal andcutaneous reconstruction are presented.

13. Treatment of Thoracic Outlet Syndrome byRemoval of First Rib and Related Entrapments Through A Posterolateral Approach:A 22-Year Experience

CLIVE R. JOHNSON, Fort Worth, Texas

Since February 4, 1952, 110 operations on 100 patients have beenperformed (bilateral in 10). Periosteum of first rib with insertions of scalenemuscles were removed. In addition to the first rib, 58 related entrapments ofbrachial plexus and related vessels in 63 operations required correction: (1)cervical rib - 13; in 6 of these a fibromuscular band extended from tip of ribto area first rib anteriorly; (2) deformity one or both first and second ribs -7; (3) fibromuscular band in absence of cervical rib - 9; (4) hypertrophy orabnormal anatomical relationship scalene muscles - 9; (5) cicatricial changesusually with periosteal proliferation and ossification in some involvinginsertions scalene muscles - 13; (6) miscellaneous - 7. Twenty patients werereferred having had previous surgery without benefit. No operation wascomplicated. There was no injury to brachial plexus, subclavian artery or vein.Postoperative course was satisfactory in all patients, there beingcomplications in four, all minimal and manageable. Current followup wasavailable in 85 patients. In 79 excellent results have been maintained withimprovement in 5. One patient expressed no benefit. Subjective manifestations,although variable, are recognizable and there is adequate objectivity foraccurate evaluation and assessment for surgical indication. Oscillotonometricrecording of radial pulse during outlet maneuvers, electromyographic testingand cinegraphic study of coronary arteries have been helpful. The chest paincomponent of the syndrome with the arm pain accounts for applicability of thelatter. This program has been gratifying. It probably represents an endeavor,however, not generally as well acccpted as deserved. Encouraged by severalclinical associates involved in this experience, a report of it is submitted.

14. Primary Breast and Lung Carcinoma in the SamePatient

WILLIAM G. CAHAN, EL B. CASTRO,*

and ANDREW G, HUVOS,* New York, N.Y.

From 1949 to 1970 at Memorial Sloan-Kettering Cancer Center, there were33 patients who had separate primary cancers of both breast and lung.

There were 30 females and 3 males with anaverage of 62 years. Eleven primary lung cancers (34%) were asymptomatic anddiscovered by follow-up chest x-ray; in 6 others, these were discovered atautopsy.

In 26, the lung cancers were foundsubsequent to the breast cancer; in 7, they were synchronous with it.

During the same period, there were 22 solitary breastcancer metastases. Therefore, in this clinical setting, there is about an equalchance that a solitary lung shadow may be either a new primary lung cancer(56.8%) or a breast metastasis. As the treatment of breast and lung cancer isdifferent, it is mandatory to establish the correct diagnosis. Occasionallythis can be done by cytology but usually an exploratory thoracotomy and biopsyare required for pathological confirmation. In addition, at that time,appropriate therapeutic measures may also be carried out.

Seven patients (21%) survived two or moreyears and one survived five years following resection of lung cancer. Incontrast, 10 out of 13 patients who had irradiation only, died within one year;none survived beyond two years.

Although these figures do not appearencouraging, in part this could be attributable to the delay in detecting andtreating the second cancer.

Implicit in this study is the need fordiligent follow-up of-breast cancer patients at regular intervals includingperiodic postero-anterior and lateral chest x-rays, for the earlier a cancer isdetected, be it a new primary or a metastasis, the better the chance for itscontrol.

15. Bronchoplasticand Conservative Resective Procedures for Bronchial Adenoma

ROBERT J. JENSIK, L. PENFIELD FABER,

CHARLES M. BROWN,* and C. FREDERICKKITTLE,

Chicago, Illinois

Recent "reports in the literature have suggested an aggressive, moreradical resection for bronchial adenoma.

We feel the surgical approach should be planneddepending upon the anatomic position and the histologic type of adenomaencountered, believing the carcinoid variety lends itself to conservative orbronchoplastic procedures. Pulmonary parenchyma is salvaged and cure rates arecomparable to reported series of carcinoid adenoma treated by conventionalresection.

Conservativeresection was accomplished in 22 individuals of a group of 32 patients withcarcinoid adenoma seen over the past 17 years. Eight patients had sleeveresection of either the lobar (6) or stem bronchus (2), and two patients hadlocal bronchotomy excision. All would have required pneumonectomy byconventional resection standards.

Sleeve segmentectomy was carried out in two otherswith anastomosis of the basilar bronchus to either the bronchus intermedius orleft main bronchus preserving the major portion of the lower lobe.

Segmentectomy done in 10 others salvagedsubstantial portions of the involved lobe.

Survival rate by actuarial methodapproaches 90% over this 17-year period, and local recurrence has not been seenin any patients undergoing conservative procedures.

Specialemphasis will be directed toward the various types of bronchoplastic proceduresperformed and the results.

16. Long-Term Results of Surgery for BullousEmphysema

MUIRIS X. FITZGERALD,* Boston, Mass.,

PATRICK J. KEELAN,* Dublin, Ireland,

DAVID W. CUGELL,* Chicago, Illinois, and

EDWARD A. GAENSLER, Boston, Mass.

Reports of surgery for emphysemagenerally have involved small numbers of patients, variable selection criteriaand short observation periods with improvement often pronounced on subjectivegrounds alone. Therefore, 21 years ago, we began a prospective study usingclinical, radiologic and physiologic indices to classify bullae and to definethe natural history, results of surgery and features which might predict afavorable outcome.

Since 1952, 368 cases of airspacedisorders were referred. For this report we excluded bronchogenic cysts, lobaremphysema, unilateral hyperlucent lung and bullae secondary to fibrosis. Thisleft 211 patients with clearly demarcated bullae in otherwise healthy lungs orassociated with chronic bronchitis and/or emphysema. Of these, 85 had surgery,11 bilateral. Patients were followed for a mean of 7.3 years and up to 20years. Surgery was advised but not performed in others who were similarlyfollowed as controls. Indications for operation included dyspnea (57),pneumothorax (18), "prophylaxis" (12), infection (6), and miscellaneous (3).

Operative mortality was 2.1% reflecting perhapsconservative or judicious selection in a group where 42% were over age 50.Physiologic results initially were excellent in 63%, moderate in 16% andinsignificant in 21%. Striking improvement occurred most often in paraseptal(periacinar) emphysema and following multiple plications. Poorer results wereseen after segmental or lobar resections and inchronic bronchitis. Long term outcome will be compared to un-operated patients.Bullae rarely recurred on the operated side; occasionally, contralateralenlargement was noted.

Simpleoverall function tests were convenient and reliable in assessment. The extentof emphysema was best substantiated by angiography and diffusing capacitymeasurement. Comparison of plethysmographic and Helium FRC values was useful inestimating trapped gas. Regional function studies, including bronchospirometryand perfusion scans, as well as elastic recoil measurements yielded usefulinformation but were associated with low patient acceptance or high cost.