TUESDAY MORNING, APRIL 29,1980

8:30 A.M. Scientific Session - Continental Ballroom

17. Candida Esophagitis Following Heart Surgery and Short-term Antibiotic Prophylaxis

STEVEN R. GUNDRY*, A. MICHAEL BORKON*,

CHARLES L. McINTOSH* and ANDREW G. MORROW,

Bethesda, Maryland

Dysphagia and retrosternal pain are common complaints in patients after heart surgery; most often they result from the median sternotomy and/or endotracheal intubation. While Candida esophagitis is a recognized cause of similar symptoms, it is usually not suspected except in immuno-logically compromised hosts. We present four patients, not immunosup-pressed or cachetic, who develop persistent dysphagia during recovery from open heart operations; three patients received only four days of pre-and post-operative prophylactic antibiotic treatment with Kefzol® and Keflex®. A naso-gastric tube had been used for less than 24 hours in the post-operative period. The fourth patient developed symptoms following prolonged and varied antibiotic therapy. Candida esophagitis was diagnosed by a combination of coexisting oral candidiasis (3/4), roenteno-graphic appearance on barium swallow (4/4), endoscopy (4/4) and biopsy or culture (2/4). Initial therapy consisted of antireflux measures and antacids (4/4), Cimetidine (4/4), oral Nystatin in methylcellulose base (one million units every four hours 3/4), and termination of other antibiotic therapy (1/4). These measures were effective in clearing the infection in only one patient. A second patient required prolonged massive oral Nystatin therapy, while two patients required intravenous Amphotericin B to control their infections. Two patients subsequently developed strictures which necessitated multiple esophageal dilatations. One of these patients developed endocarditis during home dilatation therapy. All patients are currently free of disease.

Thus, Candida esophagitis can and does occur after short term antibiotic therapy in patients without immunosuppression. Because of the high morbidity in patients treated according to current recommendations, early diagnosis and aggressive treatment is essential. Due to the frequent occurence of this post-operative symptomatology, a high index of suspicion is required to make the diagnosis.

*By invitation

18. Extended Cervical Esophagomyotomy for Cricopharyngeal Dysfunction

MARK B. ORRINGER, Ann Arbor, Michigan

Forty adult patients have undergone a 7-10 cm cervical esophagomyotomy (from the upper edge of the left thyroid cartilage to behind the clavicle) for cricopharyngeal dysfunction. A Zenker's diverticulum was present in 12 patients (30%), and in 5 was recurrent. Preoperative symptoms included cervical dysphagia (95%), expectoration of saliva (40%), and intermittent hoarseness (30%). Four patients were being fed through feeding tubes because of total inability to swallow. "Heartburn" was experienced by one-half of the patients, but only 12 had acid or food regurgitation. The duration of symptoms ranged from 1 month to 11 years (average 3.9 years). Weight loss had occurred in 15 patients (38%) and ranged from 5.5-40.9 kg (average 16 kg). Barium swallows were "normal" in 10 patients. Abnormal findings included a Zenker's diverticulum (12), prominent cricopharyngeal sphincter (11), nasopharyngeal reflux and/or incoordinated initiation of deglutition (7), a sliding hiatal hernia (11) and abnormal esophageal motility (7). Esophageal manometry revealed abnormalities of upper esophageal sphincter function in only 16 patients. Of 36 patients undergoing standard acid reflux testing, one-third had moderate-to-severe gastroesophageal reflux. Seven patients underwent staple-resection of a Zenker's diverticulum at the time of cervical esophagomyotomy. Postoperative complications included transient vocal cord paresis (4), vocal cord paralysis (1), and salivary fistula (1). There were no postoperative deaths. After 2-48 months (average 16 months) of follow-up, 33 patients (83%) have had a good to excellent result, and 7 (17%) have not been benefitted by operation.

Conclusions: The diagnosis of cricopharyngeal dysfunction must frequently be made on clinical grounds in a patient complaining of cervical dysphagia or a "lump in the throat", expectoration of saliva, and intermittent hoarseness with or without weight loss. There may be no objective radiographic, manometric, or endoscopic abnormalities. An extended cervical esophagomyotomy relieves symptoms in a substantial number of these individuals, ensures that all incoordinated pharyngoesophageal muscle is divided, and is a relatively low-risk procedure for which the gain may be great in appropriately selected patients.

*By invitation

19. The Intercostal Pedicle Method for the Control of Gastroesophageal Reflux in the Presence of Esophagogastrostomy: 12-Year Clinical Results

N. J. DEMOS and R. M. BIBLE*, Short Hills, New Jersey

The experimental study of a new technique used for the prevention and treatment of reflux esophagitis was presented in this Society in 1967. During the last 12 years the intercostal pedicle has been used in 34 resected cancer patients, in 6 bypassed cancer patients, and in 3 patients with esophageal resection for benign disease.

The cancer patients were followed up to 6 years and the benign ones up to 12 years. The operative mortality was 1/34 in the resected cancer patients, 1/6 of the bypassed ones, and 0 in the benign ones. History, histology, fluoroscopy, esophagram, fiberoptic esophagoscopy, and motility and pH studies have been used to study the function of the new sphincter upon the esophagogastrostomy.

There has been uniform absence of symptomatic or observed reflux or esophagitis. The x-ray appearance is that of a sling-like antireflux mechanism. The immediate postoperative LES pressure has been up to 26 mm/HG settling to a 12-15 mm/HG in the long term follow-up. There is a sharp rise in pH from 1-2 to 6 at the LES. Competency has also been observed in the only 2 patients with postoperative leaks which closed spontaneously. Only 1 patient required occasional dilatation but has a competent sphincter.

The procedure is advocated for the patients with absent cardia. Its advantages are (1) ease of performance at any level in the chest, (2) easily and bilaterally available pedicles, (3) a living functional sphincter whose tightness can be adjusted at will, (4) interposition of intestinal segment is avoided, (5) only 15-20 minutes of operative time are required and (6) protection of the esophagogastrostomy against leak.

*By invitation

20. The Contribution of Endoscopy to the Study of the Pathogenesis of Esophageal Adenocarcinoma

M. SAVARY* and A. P. NAEF*, Lausanne, Switzerland

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

The gastric mucosa of the cardia, the esophageal glands, and the presence of ectopic columnar mucosa have all been suspected to be at the origin of adenocarcinoma of the esophagus.

The endoscopic study of 387 cases of complicated peptic esophagitis (stage IV), carried out with serial endoscopic pictures and biopsies, showed that in 221 cases (60%) columnar epithelial clusters were also present.

Repeated endoscopic controls have confirmed the acquired character and progressive nature of this columnar epithelisation of the lower esophagus: this process represents therefore a metaplasia scarring of peptic ulcerations.

Metaplasia columnar epithelial linings usually stabilize after surgical cure of the gastro-esophageal reflux. Some endoscopic controls performed more than ten years after a Nissen-operation, have not shown any new changes in their pattern.

We have observed the association of adenocarcinoma of the esophagus in the presence of columnar epithelial metaplasia in 18 patients, all belonging to the groupe of 117 cases where the esophageal columnar metaplasia was diffuse and in continuity with the gastric mucosa (i.e. columnar epithelial lined lower esophagus). This represents a frequency of 15%.

Twice, repeated esophagoscopies have allowed us to witness the appearance of an adenocarcinoma at the level of a cluster of columnar metaplasia epithelium.

In conclusion, the frequency of the association of an adenocarcinoma with complicated peptic-esophagitis, increasingly mentioned in the literature, could be explained by a specific scarring process of chronic peptic ulcerations with re-epithelisation by metaplasia gastric columnar epithelium, instead of the usual squamous type.

INTERMISSION - 45 MINUTES

VISIT EXHIBITS

*By invitation

21. Pectus Excavatum: Late Results without Surgery and Following Operation

GEORGE H. HUMPHREYS II and ALFRED JARETZKI III,

New York, New York

Decision on operations to correct Pectus Excavatum depend on knowledge of late results. Few surgical reports answer these questions:

1. What can be expected without surgical correction?

2. What are the late results of surgical procedures?

3. If operation is justified, what are the indications?

Records of all patients on whom the diagnosis was made in one medical center during thirty years were reviewed. Of 334 patients, 168 had no attempted correction; 174 operations were done on 166.

A. In those not operated:

1. Mortality, especially in infancy, was high.

2. Of the 52% with known late results, the deformity disappeared or improved in 36% up to age 6, after which it remained the same or worsened with age.

3. Mild deformities were compatible with long life and few or no symptoms.

4. Severe deformities were associated with chronic disabling symptoms.

B. In those operated:

1. There was no surgical mortality. The result meant little until more than five years after operation.

3. Late results were determined on 106 operations performed on 102 of the 122 patients done more than five years ago (84%).

4. Late results were satisfactory in 68 of the 102 patients (67%).

5. Late results tended to become worse with patient's age at follow-up.

6. The method of correction was more clearly related to the late result than sex, severity, age at operation or time after operation.

CONCLUSIONS

1. Surgical correction of Pectus Excavatum is justified in suitable cases.

2. Radical operations yielded better ultimate results than simpler ones.

3. The final result cannot be judged until the patient is fully grown.

4. Better objective methods of evaluation of all patients over a period of 15 to 20 years is necessary in order to judge the value of any corrective operation.

22. Thymectomy for Myasthenia Gravis in the Young Adult -Long Term Results

RICHARD E. CLARK, JACK B. SHUMATE*,

MICHAEL H. BROOKE*, JOHN P. MARBARGER*,

PHILIP N. WEST*, CHARLES L. ROPER,

THOMAS B. FERGUSON, and CLARENCE S. WELDON,

St. Louis, Missouri

This 7 year study involved 28 young adults ages 14-35 who had thymectomy as primary therapy for myasthenia gravis (MG) prior to failure of anticholinesterase and/or steroid medication. The diagnosis was established on both clinical and electromyograph bases. Most had preoperative muscle biopsies and more recently tomographic scans of the chest. Extensive objective testing of muscle strength and pulmonary function was performed pre and post operatively. All had a median sternotomy and wide dissection of the thymus. Special care was taken to obtain all thymic tissue and lymph nodes in the two tails of the gland into the neck. 93% received prostigmin in the immediate post operative period and 96% were then given mestinon. Prednisone 100 mg q.d. was given to all after the 7th post operative day and the mestinon discontinued over several months. Follow-up intervals range from 7 to 0.5 years (mean = 2.1 year). There have been no operative, perioperative or long term deaths. Careful follow-up by the Muscle Study Group with objective testing has shown 62% have excellent results without use of anticholinesterase drugs and minimal dosage of prednisone. 11 % have had a good response and 23% are improved but require mestinon. To date, no patient who has had an excellent or good response to thymectomy has an exacerbation of symptoms of MG. Only one patient who had congenital MG (4%) failed to respond to thymectomy. One patient in this series had a malignant thymoma. It is concluded that thymectomy early in the course of myasthenia gravis is efficacious and appears to have a lasting effect.

*By invitation

23. Trends in Cardiac Surgery: A 5-Year Study of a Defined Population

ROBERT H. KENNEDY*, MARGARET A. KENNEDY*,

JAMES R. PLUTH and FRED T. NOBREGA*,

Rochester, Minnesota

To provide population based information on cardiac surgery that would be useful in developing appropriate planning guidelines, the total number and types of cardiac operations performed on residents of Olmsted County, Minnesota, from 1973 through 1977 were studied through use of the medical records linkage system at the Mayo Clinic. During this time, 213 patients underwent 224 operations. A total of 104 patients (87 males and 17 females) had only coronary artery bypass operations, 94 (44 males and 50 females) had only other cardiac surgical procedures, and 15 (10 males and 5 females) had both. The overall number of cardiac operations per 10,000 population of all ages increased from 4.2 in 1973 to 6.2 in 1977. Non-coronary artery bypass operations showed no significant trends over time and the average rate was 2.7 per year. The number of coronary artery bypass operations per 10,000 population 25 years of age or older increased from 2.7 in 1973 to 7.0 in 1977 (P<0.01). Age-specific rates for patients who had coronary artery bypass operations were greatest in the 45 through 64 year age group. For those who had other cardiac operations the rates showed a peak in the less than 5 year age group, but were greatest among patients 65 years of age or older. The average annual number of open heart operations per 10,000 population less than 15 years of age was 2.1 and the 1977 rate for patients 15 years of age or older was 7.4. On the basis of these rates adjusted by age and sex to the 1970 United States white population, a population of approximately 350,000 less than 15 years of age would be required to assure use of a pediatric cardiovascular surgical facility at the minimum level of 75 cases requiring open heart operations per year and a population of approximately 225,000 greater than 14 years of age would provide 200 adult open heart cases per year. Thus, total populations of approximately 1,275,000 and 310,000 of all ages would be required to meet these minimum standards for pediatric and adult open heart operations.

11:30 A.M.	Address of Honored Speaker
	CARDIO-THORACIC METAMORPHPOSIS
	H. D' Arcy Sutherland
	Melbourne, Australia

*By invitation