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