TUESDAY AFTERNOON, MAY 9,1978
2:00 P.M. Scientific Session - Regency
Ballroom
21. Role of Angiography in Cervico-Thoracic Trauma
ARTHUR N. THOMAS and
PHILLIP C. GOODMAN*
San Francisco,
California
During 11 years, emergency angiographic evaluation
was obtained in 253 patients. One hundred patients had penetrating cervical
wounds, 43 stabs and 57 gunshots. One hundred fifty-three patients had thoracic
injuries, 100 severe blunt trauma and 53 penetrating injury, -34 gunshot and 19
stabwounds. Angiography was used in 19% of all patients seen with penetrating
neck injuries and 3% of patients with severe blunt or penetrating thoracic
injury.
Patients with
suspected vascular injuries who responded to resuscitation had angiographic
assessment. The indications in penetrating injuries were the location of wounds
or missile fragments; history of spurting blood; or presence of hematoma. In
blunt trauma, evidence of severe injury such as: mediastinal widening;
fractures of the first rib, sternum, transverse processes or vertebrae;
abnormalities of the cardiac silhouette; or diaphragmatic rupture.
Vascular
injuries were discovered by angiography and included disruptions of the
thoracic aorta (5); major artery to vein fistula (3); or interruption of the
subclavian (14), carotid (9), or vertebral arteries (8). Other vascular
injuries were identified in 17 cases. Angiographic visualization of vascular
injuries occurred in 10/43 of neck stabwounds, 15/57 of neck gunshot wounds,
22/100 of blunt chest trauma, and 7/34 of chest gunshot and 0/19 chest
stabwounds. Overall, 54/253 (21%) were positive.
Angiographic
results were useful whether positive or negative. In cases with a positive
finding, operative treatment can be specific and improper incisions avoided. In
cases with negative angiography, clarification of the vascular status avoids
unnecessary thoracotomy and permits a definitive and concentrated therapeutic
effort upon injuries to other systems. These results are compared to vascular
injuries in other cervico-thoracic trauma patients who had unresponsive shock
or profuse hemorrhage necessitating immediate operation.
*By invitation
22. Physicians' Assistants on a University
Cardio-Thoracic Surgical Service-A Five Year Update
JOSEPH I. MILLER*
and CHARLES R. HATCHER, JR.,
Atlanta, Georgia
In 1973, two physicians' assistants (PA's) were
employed on the Cardio-Thoracic Surgical Service at Emory University Hospital,
and in 1974 our initial experience with these paramedical personnel was
presented to this Association. Since that time seven additional PA's have been
added to our Service. They are now employed in four hospitals of the Emory
University's Woodruff Medical Center. New guidelines and regulations have been
imposed at both the State and Federal level regarding PA's, and their role in
our Center has become rather well-defined. With over 1,500 cardiac cases and
400 thoracic cases per year to cover on our Service, the physician's assistant
has assumed a position of increasing importance both in operating room
assistance and pre-operative and postoperative care. Since the University has
maintained a constant number of residents and fellows during this interval,
PA's have filled needs of expanded clinical service in the various hospitals.
In the pediatric and community hospitals associated with the University, the
physician's assistant now functions as a junior house officer. In our
University Center with a large resident staff, their role has become narrowed
with definite guidelines. A credentials committee now governs the hiring of all
physicians' assistants by the University.
When properly utilized and supervised, the
physician's assistant can be a vital member of the cardio-thoracic team. This
report details our experience with PA's for the past five years-culminating a
staff of nine PA's working on our service in four types of hospitals within a
University Medical Center.
*By invitation
23. Bronchopleural Fistula: A Thirteen-Year
Experience with Seventy-Two Cases
JOHN R. HANKINS,
JOHN E. MILLER*, SAFUH ATTAR,
and JOSEPH S.
McLAUGHLIN, Baltimore, Maryland
During the period 1963-1976, 72 patients were
treated for broncho-pleural fistula. The underlying disease was tuberculosis in
58 patients, carcinoma in 8, lung abscess in 2, and other infections in the
remaining 4. In 19 patients the fistula developed on the basis of the
underlying disease and was present on admission. In 53 patients the fistula
developed after a pulmonary resection. The highest incidence of fistulas
occurred after lobectomy combined with segmental or wedge resection. The most
prevalent etiologic factors appeared to be: the presence of a sputum culture
positive for M. tuberculosis preoperatively, intercurrent illness, poor
nutrition, and faulty surgical technique - particularly the leaving of a long
bronchial stump.
The establishment of adequate dependent surgical
drainage was the sine qua non of effective treatment. This procedure alone
brought about closure of the fistula in 9 (21%) of the 43 patients in whom this
was achieved. The majority of the other patients required multiple surgical
procedures before healing was effected. Overall, the highest rate of fistula
closure and the lowest mortality rate was obtained in the group of 20 patients
who underwent muscle flap transfer (myoplasty) usually combined with a limited
thoracoplasty. In this group, 16 patients (80%) had their fistulas obliterated
and only 1 died.
For the entire series closure of the fistula was
obtained in 68% of the patients. The mortality for the series was 22%. Though
the incidence has declined in recent years, bronchopleural fistula still
represents a challenge to the thoracic surgeon. Only by an energetic approach
can the closure rate be raised and the mortality reduced.
*By invitation
24. Esophagectomy Without Thoracotomy
MARK B. ORRINGER and
HERBERT E. SLOAN,
Ann Arbor, Michigan
Sixteen patients have undergone total thoracic
esophagectomy utilizing blunt dissection of the esophagus from the mediastinum
through upper abdominal and cervical incisions without a thoracotomy. Esophagectomy
was performed for cervico-thoracic carcinoma (6 patients), middle third
carcinoma (4 patients), distal third carcinoma (2 patients), post-irradiation
stricture (2 patients), post-cricoid carcinoma (1 patient) and acute caustic
injury (1 patient). Of 6 patients who required concomitant
laryngopharyngectomy, 4 underwent anterior mediastinal tracheostomy.
Gastrointestinal continuity was re-established
through the posterior mediastinal route at the time of esophagectomy (15
patients) or sub-sternally after 4 weeks (1 patient). The stomach was the
visceral esophageal substitute in 13 patients and the colon in 3. The types of
anastomoses included cervical esophagogastrostomy (7), pharyngogastrostomy (6),
cervical esophagocolic (2) and pharyngocolic (1).
Operative and perioperative complications related to
transmediastin-al esophagectomy were pneumothorax (5 patients) and pleural
effusion (3 patients). No excessive bleeding occurred intraoperatively during
mobilization of the esophagus. The 3 postoperative deaths in this group were
from a cerebrovascular accident (1), innominate artery rupture (1), and
anastomotic disruption with sepsis (1) and were not directly related to the
technique of esophagectomy.
Blunt transmediastinal esophagectomy carries less
morbidity than standard esophagectomy via a thoracotomy. The procedure is
applicable for both benign and malignant esophageal disease, affords optimal
access to the abdomen for mobilization of the visceral esophageal substitute,
and requires re-establishment of gastrointestinal continuity in the neck, thus
eliminating the hazards of an intrathoracic anastomotic disruption. This
technique is not advocated for use in patients with evidence of
tracheobronchial involvement by esophageal neoplasm.
INTERMISSION - VISIT EXHIBITS
*By invitation
25. Gastroesophageal Fundoplication for Management
of Reflux in Infants and Children
ERIC W. FONKALSRUD,
MARVIN E. AMENT*and
WILLIAM J. BYRNE*,
Los Angeles, California
With the development of more sophisticated
diagnostic techniques in Pediatric Gastroenterology, gastroesophageal reflux
has been recognized with increasing frequency as a cause of a wide variety of
symptoms in infants and children. During the past 8 years at the UCLA Hospital
60 patients under eighteen years of age have been identified as having
sufficiently severe, symptomatic reflux to warrant gastroesophageal
fundoplication. Although repeated emesis was the most common primary symptom,
failure to thrive was the major symptom in 22 patients, unexplained repeated pneumonia
in 14, asthma in 6, and dysphagia in 5. Five children with previously repaired
esophageal atresia had severe reflux. Severe neurologic disorders were present
in 14 children. Twelve children had esophageal stricture.
The diagnosis
of reflux was established by a combination of positive cine esophagram (80%),
Tuttle test (85%), esophageal manometry (65%), and esophagoscopy with biopsy
(35%).
Nissen
fundoplication with gastrostomy was performed on each of the 60 children (19
under 1-year of age). Each of the strictures was successfully managed by
postoperative dilatations. There was no mortality and no major complications.
Two patients have developed radiographic evidence of recurrent reflux, although
they are asymptomatic. Four children experienced delayed gastric emptying. Each
of the children has been relieved of clinical reflux and the pulmonary status
in each, including the asthmatic children, has been markedly improved or is
normal.
On the basis of
this favorable experience it would appear that an aggressive surgical approach
should be taken in the management of symptomatic reflux in infants and
children.
*By invitation
26. Gastroplasty and Fundoplication in the
Management of Complex Reflux Problems
F. GRIFFITH PEARSON,
JOEL D. COOPER and
JOHN M. NELEMS*,
Toronto, Ontario, Canada
Between 1963 and 1976,214 patients with complex
reflux problems were managed by adding a modified Collis gastroplasty to a
Belsey hiatal repair. All patients had one or more of the following
complicating conditions which were considered indications for the combined
operation: peptic stricture (100), esophagitis and shortening without stricture
(25), one or more prior hiatal repairs (59), massive sliding hernia and
intra-thoracic stomach (32), motor disorders (26 - scleroderma 10, achalasia
10, diffuse spasm 6). The length of follow-up is one to two years (80
patients), two to five years (93 patients), five to 10 years (33 patients), and
over 10 years (2 patients).
Of 196 patients
(92%) with complete clinical follow-up, nine (5%) have significant symptomatic
reflux (4 severe, 5 moderate), and 15 (8%) have significant dysphagia (6
severe, 9 moderate). Seven of the 15 patients with significant dysphagia have
associated primary motor disorders. There were no post-operative deaths. Only
one patient has undergone a subsequent anti-reflux operation. Complications
occurred in 32 patients, and include one leak from the gastric suture line.
Recently, 20
patients in this series have been evaluated by pre-operative, intra-operative
and sequential post-operative esophageal pressure studies. The mean
pre-operative lower esophageal sphincter pressure (LESP) was 10 mmHg. One year
after operation the mean LESP was 21 mmHg. These mean post-operative pressure
values are at least double the post-operative levels recorded in two
publications from other centres reporting on a similar group of patients
managed by gastroplasty and partial fundoplication. In these latter
publications, clinical results were much less satisfactory than those recorded in
our series, and identify a high incidence of recurrent symptomatic reflux. We
suggest that the significant differences in post-operative LESP observed in
these reports are due to technical differences in the operative procedure
itself, and account for the pronounced differences in the quality of results
obtained.
4:00 P.M. Executive
Session (Limited to Active and Senior Members)- Ballroom
*By invitation
TUESDAY EVENING,
MAY 9, 1978
7:00 P.M. President's Reception
Ballroom
8:00 P.M. President's Dinner and Dance
Ballroom
Attendance open to all physicians and their ladies.
Tickets must be purchased at the registration desk by 5:00 P.M. on Monday, May
8th.
Dinner dress preferred.
