WEDNESDAY MORNING, MAY 2, 1979
8:30 A.M. Scientific Sessions - Ballroom
29. Modified Senning Operations for Treatment of
Transposition of the Great Arteries in Infancy
EDUARDO OTERO COTO*, WILLIAM I. NORWOOD*
and ALDO R.
CASTANEDA, Boston, Massachusetts
Since February 1978, 26 infants, ranging in
age from 3 weeks to 12 months (mean age 5 months) and in weight from 2.0 kg. to
8.5 kg. (mean weight 5.5 kg.) underwent a modified Senning procedure, under
deep hypothermic circulatory arrest, for correction of transposition of the
great arteries (TGA). Ten patients were less than 3 months of age and weighed
less than 4.0 kg. Eight had concommitant transatrial closure of a large VSD.
Additional defects included: multiple VSD's (1), total anamolous pulmonary venous
connection (1), and coarctation of the aorta (2). Modifications of the original
Senning operation included: (1) Patch augmentation (pericardium or Cortex) of
the atrial septal flap and (2) Pericardial patch enlargement of the pulmonary
venous atrium. Two patients died (7.5%); a 3 month old with multiple VSD's and
coarctation had Stage IV pulmonary vascular disease. The other death occurred
in a 2 month old treated with prostaglandin E1 for three weeks
before surgery. One patient with VSD had transient complete heart block and
three patients were discharged in junctional rhythm. Intraoperative
measurements (24 pts.) and postoperative catheterizations (5 pts.) showed that
none of the patients had gradients exceeding 3 mm.Hg. between superior and
inferior vena cavae to right atrial junction or across the pulmonary venous
atrium.
The potential advantages of the modified
Senning over the Mustard operation in infants include a more readily
standardized technique and the greater reliance on autogenous tissue for
construction of the atrial chambers. The use of additional material
(pericardium or Cortex) was not totally avoided, however, particularly in the
neonate or very small infant. The early postoperative hemodynamic results and
the relatively low incidence of conduction abnormalities (12%) at the time of
hospital discharge support the policy of continued evaluation.
Dr. Coto is the 29th
EVARTS A. GRAHAM MEMORIAL TRAVELING FELLOW (1978-79).
*By invitation
30. Complete Transposition of the Great Arteries
with Intact Ventricular Septum and Left Ventricular Outflow Tract Obstruction:
Surgical Management and Anatomic Considerations
CHRISTOPHER
LINCOLN*, GIANCARLO CRUPI*,
and ROBERT
ANDERSON*, London, England
Sponsored by
Mortimer J. Buckley, Boston, Massachusetts
The surgical management of patients with
transposition of the great arteries with intact ventricular septum (IVS) and
sub-pulmonary stenosis remains controversial. Although direct resection of the
obstruction is usually attempted, an alternative approach has been to place a
conduit from the left ventricle to the pulmonary artery.
Among 130 consecutive patients undergoing
Mustard's operation for repair of complete transposition at the Brompton
Hospital were 5 patients in whom sub-pulmonary stenosis required surgical
treatment. Their age at operation ranged from 13 months to 5.3 years. Each had
a combined Mustard's procedure and placement of an external conduit from the
left ventricle to the pulmonary artery. There was one hospital death.
Post-operative cardiac catheterization performed in the survivors showed good
relief of the stenosis and no significant gradient across the conduit.
Our study of the morphology of the left
ventricular outflow tract in complete transposition with IVS and sub-pulmonary
stenosis shows that the position of both the mitral valve and the conduction
tissue is such that satisfactory resection of the stenosis is difficult without
major risk of damaging these structures. Consequently, insertion of a conduit
from the left ventricle to pulmonary artery in total correction of patients
with complete transposition with IVS and sub-pulmonary stenosis represents a
good alternative.
*By invitation
31. Tracheo-Bronchial Surgery
B. V. PETROVSKY*, M.
I. PERELMAN*, Moscow, U.S.S.R.
Sponsored by Hermes
C. Grillo, Boston, Massachusetts
Between 1963 and 1977, 164 patients were operated
upon for diseases of the trachea. The lesions included, in descending order of
incidence, 76 malignant tumors, 42 benign stenoses, 17 benign tumors, 11
tracheo-esophageal fistulas, 5 malformations, 4 injuries and 4 in-falmmatory
diseases. The operations consisted of sleeve resection-51, resection of
tracheal bifurcation-29, tracheotomy for resection of tumor-14, window
resection-5, plastic repair of the membranous wall-20, repair of
tracheo-esophageal fistula-11, repair of defects in the tracheal wall-4,
palliative procedures for malignant lesions-17. There were 26 deaths.
Two hundred sixty-five operations were done on
the bronchi. These procedures were done for resections of bronchopulmonary
cancer-84, benign tumors-60, post-pneumonectomy fistula-53, cicatricial
stenosis-24, bronchoesophageal fistula-20, post-traumatic occlusion-21. There
were 141 bronchial resections with lobectomy, 30 bronchial resections, 53 resections
of bronchial stumps, 21 bronchial repairs after occlusion and 20 repairs of
broncho-esophageal fistula. There were 22 deaths.
Respiratory bypass was used principally to
maintain ventilation. In 9 complex resections hyperbaric oxygenation was
utilized to permit interruption of ventilation for periods of up to 10 minutes.
The upper trachea was approached anteriorly and the lower trachea through a
right thoracotomy.
After extensive tracheal or carinal resection
the left main bronchus was oversewn with the left lung remaining in situ. The
membranous wall was splinted in some cases of malacia with lyophilized
cadaveric bone.
If the anastomoses stenose reconstructive
procedures are repeated, only 1/3 to 1/4 of patients with adenomas or stenoses
of the large bronchi can be subjected to reconstruction.
*By invitation
32. Sleeve Resection for Carcinoma of the Lung
RICHARD D. WEISEL*, JOEL D. COOPER, NORMAN C. DELARUE,
THOMAS R. J. TODD*and F. GRIFFITH PEARSON,
Toronto, Ontario,
Canada
Sleeve resection of the bronchus for a
carcinoma in the proximal airway preserves lung tissue and permits actuarial
five year survival comparable to pneumonectomy.
Seventy patients (pts) underwent sleeve
resection of a bronchus for proximal carcinoma between 1967 and 1978. There
were 9 peri-operative deaths (13%), four from bronchovascular fistulae.
Eighteen pts (26%) had a palliative resection because all intra-thoracic tumour
could not be removed. The 1 year survival was 43% but no patient survived 5
years. Fifty-two pts (74%) had potentially curative sleeve resections with a 1
year survival of 75% and a 5 year survival of 36%. Twenty-eight pts (40%)
underwent sleeve resection because respiratory impairment prevented
pneumonectomy. The 1 year survival was 55% and the 5 year survival was 5%.
Eighteen pts in the group (64%) had curative resections, however, 11 (61%) died
post-operatively without evidence of recurrent tumour. The remaining 42 pts
(60%) had adequate pulmonary reserve but underwent elective sleeve resection
because of the anatomic position of the lesion. The 1 year survival was 84% and
the 5 year survival was 34%. Eight of the 42 pts had palliative resections with
a 38% 1 year and 15% 5 year survival. Among the 34 pts with adequate pulmonary
reserve who underwent potentially curative sleeve resections, there was an 84%
1 year and 43% 5 year survival.
Forty-five patients underwent pneumonectomy
for a carcinoma in the proximal bronchi. The peri-operative mortality was lower
(4%) although the difference was not significant (p=.13). The 8 pts who had
palliative resections had a 37% 1 year survival and none lived beyond 2 years.
The 1 year (90%) and 5 year (45%) survival of patients undergoing curative
pneumonectomies is not different from the survival of pts with adequate pulmonary
reserve undergoing curative sleeve resections. The incidence of local
(intra-thoracic) recurrence after sleeve resection at 1 year (15%) and 5 years
(54%) was not different than the incidence among pneumonectomy patients (1
year: 10%; 5 years: 56%).
Sleeve resection provides an adequate
disease-free interval for patients with impaired pulmonary reserve. In patients
with adequate pulmonary function, a curative sleeve resection provides results
comparable to pneumonectomy while preserving lung tissue.
INTERMISSION - VISIT EXHIBITS
*By invitation
33. Anterior Mediastinal Tracheostomy -
Indications, Techniques, and Clinical Experience
MARK B. ORRINGER and HERBERT SLOAN, Ann Arbor, Michigan
Anterior mediastinal tracheostomy has wider
clinical application than its initially described use for treatment of stomal
recurrences following laryngectomy for carcinoma. For this procedure provides
access to the cervico-thoracic esophagus, permitting resection and
reconstruction in an area traditionally regarded as "no-man's land". This
report reviews our experience with 14 patients who have undergone anterior
mediastinal tracheostomy for cervicothoracic esophageal carcinoma (9);
pharyngeal carcinoma following previous laryngectomy (2); stomal recurrence
following laryngectomy (1); extensive thyroid carcinoma (1); and stomal
stenosis following laryngectomy and radiation therapy for carcinoma.
Eight patients underwent concomitant
laryngopharyngectomy, 10 blunt trans-mediastinal esophagectomy, and 11 visceral
esophageal substitution using either stomach (phayngogastrostomy in 7) or colon
(pharyngocolostomy in 4). A bipedicled upper thoracic apron flap was used to
construct the mediastinal tracheostomy in 10 patients; four patients required a
thoraco-acromial rotational flap because of the need to resurface the anterior
neck following resection of skin involved with tumor. Operative techniques will
be described.
Three deaths occurring within 30 days of
operation resulted from innominate artery rupture (1), acute myocardial
infarction (1), and respiratory insufficiency (1). latrogenic
hypoparathyroidism and hypo-thyroidism occurred in 5 patients. After a period
of follow-up ranging from 2-20 months (average 10 months), satisfactory airways
have been achieved in all of the surviving 11 patients, 2 of whom developed
mild stomal stenoses which are easily dilated. Anterior mediastinal
tracheostomy enables excellent palliation in patients with selected
cervicothoracic neoplasms which compromise both the upper airway and/or the esophagus.
*By invitation
34. Surgical Treatment of Post-Intubation Tracheal
Injuries: Cumulative Experience Since 1965
HERMES C. GRILLO, Boston, Massachusetts
Since January, 1965, 201 patients with
post-intubation tracheal injury have been treated by resection and
reconstruction (to October, 1978). The injuries included stenosis, malacia, and
fistulas to esophagus and innominate artery. One hundred twelve resulted from
exposure to high pressure cuffs or to "low pressure" cuffs used in a high
pressure range. Seventy-four originated in stomal injuries. In 13, both types
of injuries were seen and in 2 the locus could not be determined. In the last 5
years the number of stomal injuries has proportionately increased.
A total of 208 operations were completed, 199
transcervically, 80 through sternotomy, 6 transthoracically and 1 by staged
reconstruction. Circumferential resection and primary anastomosis were employed
in all but 3, with care to avoid devascularization. Injury to arteries and
recurrent laryngeal nerves were avoided by close tracheal dissection. Length
was gained chiefly by minimal anterior mobilization, cervical flexion, plus
laryngeal release in 17. Partial cricoid resection to the anterior commissure
was necessary in 8 patients.
Technical problems were posed by lesions
involving the subglottic larynx, previous operations, extraordinary lengths of
damage and individual anatomy. Stomas were variously managed-left in place,
excised in continuity, replanted or closed.
Five deaths followed resection, only one in a
truly elective case. Sutureline granulations were the most common complication.
Rest-enosis occasioned 7 reoperations. Other rare complications included one
innominate arterial hemorrhage, wound infections, hoarseness and dysphagia.
Results were generally good anatomically and functionally as determined by
systematic follow-up. The lessons learned over the 14 years encompassed will be
detailed.
35. Screening for Bronchogenic Carcinoma - The
Surgical Experience
R. ROBINSON BAKER,
MELVYN S. TOCKMAN*,
BERNARD R. MARSH*,
FREDERICK P. STITIK*,
WILMOT C. BALL, JR.
*, JOSEPH C. EGGLESTON*,
YENER S. EROZAN*,
MORTON LEVIN* and
JOHNK. FROST*,
Baltimore, Maryland
This paper describes the surgical experience with a
project designed to detect early lung cancer. The screening population
consisted of 10,362 males. Half of the patients had sputum cytologies and a
chest x-ray, the other half had a chest x-ray. Seventy-one bronchogenic
carcinomas were detected in the initial screen, 34 patients in the sputum cytology
plus x-ray group, 37 patients in the x-ray group alone. Following clinical
assessment including mediastinoscopy and mediastin-otomy in selected cases, 38
of the patients had exploratory thoracot-omies. Thirty-six of these patients
(95%) had tumors resected for cure, 75% by lobectomy, the remainder by sleeve
resection or pneumon-ectomy. At thoracotomy, the mediastinum was evaluated by
palpation, only suspicious nodes were removed for histologic study and none of
these nodes were found to contain histologic evidence of metastases. The three
year survival rate of patients with Stage 0 disease was 100%, Stage I disease -
70%, and Stage II - III - 17%. This study demonstrates a higher resectability
rate in comparison to previous studies, i.e. 50% of the tumors detected were
resected and in all instances but one, the patient could tolerate a
thoracotomy. The survival rates obtained thus far were obtained in patients who
did not have the mediastinal nodes routinely removed at thoracotomy. Although
adjuvant therapy is clearly indicated in patients with Stage II and III
disease, the advisability of currently available adjuvant therapy in patients
with Stage I disease and a 70% chance of survival is open to question.
*By invitation
36. Treatment of Far Advanced Bronchogenic
Carcinoma by Extracorporeal Induced Systemic Hyperthermia
LEON C. PARKS*,
DEANNA MINABERRY*, DOYLE P. SMITH*,
and WILLIAM A.
NEELY, Jackson, Mississippi
Hyperthermia (HT) of 41.5° to 42.0°C was induced in patients (P) with
pre-terminal bronchogenic carcinoma by use of a heat exchanger incorporating,
TDMAC-treated, extra-corporeal circuit (ECC) cooperative with a dacron femoral
arteriovenous shunt. A Temperature Regulating Device (TRD) autoregulated heat
exchanger and thereby patient temperature (T) ± 0.1°C as measured in the
urinary bladder with a thermistor-tipped foley catheter.
A total of 76 treatments averaging 4 hrs. in
duration were administered to 22P, 20 of whom had failed previous
radiation/chemotherapy. Cytoxan 250 mg/M2 and BCNU 50 mg were given
during mid-HT. The distribution of tumor histology was 13 (59%) squamous, 4
(19%) large cell, 2 (9%) adeno, 2 (9%) oat cell, and 1 (5%) alveolar cell
carcinoma.
Adverse effects were principally moderate
marrow suppression. Neurologic abnormalities occurred early in the series, but
were eliminated by maintenance of serum phosphate levels. Fifteen (68%)P have
died, 11 of tumor progression only 2 of whom completed their treatment series,
4 from infection or bleeding of necrosing tumor, and 1 of treatment
complications. Patients post pneumonectomy or with significant COPD adequately
tolerated treatment. There was no instance of ECC related hemolysis,
thromboembolism, or significant cardiac failure.
Of 11P at risk for 2 or more months an antitumor effect was evidenced by
x-ray or histologic findings in 9 (69%). Regressions were typically incomplete
and progression occurred at 4-6 months post HT in 5 of the 8P at risk. Three P
have stable regressed disease 6,7, and 13 months post HT.
Conclusion: These data suggest: (1)
Hyperthermia can regress bronchogenic carcinoma resistant to other modes of
therapy; (2) Hyperthermia of 4 hrs. duration and 41.5 to 42.0°C magnitude will
not routinely control bronchogenic carcinoma even with adjuvant cytotoxic agents;
(3) Further exploration of treatment regimens, particularly as applied to
minimal residual disease, may be indicated.
Luncheon Intermission until 2:00 P.M. - Visit Exhibits
12:15 P.M. Panel of Experts Luncheon for Cardiothoracic
Residents - Fairfax Room
*By invitation
