TUESDAY AFTERNOON, MAY 12, 1981

2:00 P.M. Scientific Session - International Ballroom

22. Lye Ingestion: Clinical Patterns and Therapeutic Implications

DAVID D. OAKES*, JOHN P. SHERCK* and

JAMES B. D. MARK, San Jose and Stanford, California

During the past ten years we have admitted 42 patients following ingestion of caustic substances. This report evaluates the efficacy and safety of traditional diagnostic and therapeutic maneuvers - specifically diagnostic endoscopy, early dilitation, and steroid therapy. It also examined the role of emergency esophagogastrectomy as advocated by Kirsh et al. There were 16 children (ages 1-7, mean 2.6 years) and 26 adults (ages 17-70, mean 34.7 years). The substance ingested was liquid in 29 cases, solid in 8, and in-determinant in 5. Twenty-four patients underwent early endoscopy, 27 had esophagograms, 13 had both studies, and 5 had neither. All patients were started immediately on antibiotic and steroid therapy. In selected patients early esophageal dilatation was attempted. There were three clinical groups: Group I - Twenty-two patients proved to have no significant esophago-gastric injury. Burns were limited to the lips, anterior tongue, or cheeks - with only edema or erythema in the oropharynx. History suggested that weak agents or small quantities had been ingested. Endoscopy was performed in 12 patients and confirmed the clinical impression. Group II - Thirteen patients had small burns of the posterior oropharynx. Esophageal involvement was seen at endoscopy in 8 (diffuse "esophagitis" 2, segmental burns or ulcers 4, unspecified "burns" 2). Three patients had gastric lesions (2 had ingested capsules). The final two patients had no dysphagia and were not endoscoped; one had a normal esophagogram. All recovered uneventfully with antibiotics, steroids, and supportive care. Group III - Seven patients sustained extensive burns of the mouth and esophagus and - in spite of steroid therapy - required bypass procedures. Early dilatation led to three perforations. No patient required emergency esophagogastrectomy, although one gastrectomy was necessary on the eleventh hospital day. In every case the extensive nature of the injury was apparent from the initial examination. CONCLUSIONS: Precise knowledge of the agent ingested combined with examination of the oropharynx will allow most patients to be classified as to the probability of esophageal injury. Rapid, accurate clinical assessment - aided by cautious early endoscopy - will affect therapy in that steroids are unnecessary in Group I and ineffective and potentially dangerous in Group III. (Although widely used, their value in Group II is moot.) Early dilatation is dangerous and ineffective. Emergency esophago-gastrectomy has not been required in our experience.

*By invitation

23. Treatment of Gastroesophageal Reflux in Children with Thai's Fundoplication

KEITH W. ASHCRAFT, THOMAS M. HOLDER and

RAYMOND A. AMOURY*, Kansas City, Missouri

The surgical treatment of gastroesophageal influx in childhood is necessary when positional treatment feedings fail to relieve the symptoms of relux. Nissen's fundoplication has been advocated most frequently as being the ideal operative treatment. We present a series of 362 patients treated surgically by a partial wrap (Thai fundoplication) over a period of seven years. This fundoplication has the distinct advantage in permitting the child to vomit if necessary postoperatively.

Operative indications in this group of 362 patients included 203 whose primary symptoms were respiratory, 26 with esophagitis and 126 with intractable vomiting or nutritional failure. Seven patients had fundoplication done along with gastrostomy for feeding for CNS disorders to prevent aspiration. Two-hundred and sixty patients were under the age of one year. Twenty-seven patients were lost to follow-up leaving 335 patients followed for a minimum of eight months and up to seven years. The results of Thai's fundoplication are shown in the Table.

The 17 patients who failed initially were redone for a 95% satisfactory outcome. The patients frequently were able to burp postoperatively and certainly could vomit when necessary. There were no instances of the gas/bloat syndrome. There were no deaths due to operation. The usual hospital stay is 3 days.

The Thai fundoplication appears to be a very satisfactory alternative to the Nissen fundoplication with some disinct advantages for the growing child.

*Error in assuming GER responsible for symptoms.

*By invitation

24. Esophageal Replacement Using Jejunum in Children - An 18 to 33 Year Follow-up

W. STEVES RING*, RICHARD L. VARCO,

PHILIPPE R. L'HEUREUX* and JOHNE. FOKER*,

Minneapolis, Minnesota

Esophageal substitutes in children must provide satisfactory long-term function and freedom from problems. Colon and stomach tubes are most frequently used for esophageal replacement but functional and pathologic abnormalities have been reported with each which raise concern over their long-term suitability. The jejunum is a nearly disease-free organ, and therefore has a thoretical advantage over both colon and stomach as an esophageal substitute. From 1947 through 1962, staged juejunal interposition was performed in 16 children with esophageal atresia. There were no failures of the jejunum to reach the neck, loss of graft or operative mortality. Cervical fistulas occurred following esophagojejunostomy in 25% (4/16) but closed spontaneously in all patients and did not result in stenosis requiring dilatation or surgical revision. Stenosis of the cervical anastomosis sufficient to require dilatation but not revision occurred in one patient (6%). Long-term follow-up (range 18-33 yrs.; mean 27 yrs.) was obtained in 100% (16/16) of patients. A barium swallow was performed in 81% (13/16) at a mean of 25 yrs. (range 14-33 yrs.) following initial reconstruction. No or minimal swallowing difficulties were reported by 88% (14/16) and they eat a completely normal diet at normal speed. Two patients (12%) reported moderate dysphagia. No obstruction was demonstrated by barium swallow in one patient. The other was found to have an esophageal diverticulum proximal to the cervical anastomosis which was recently excised, 27 years following the initial reconstruction. In all 13 patients studied, the interposed jejunum had normal peristalsis and mucosal pattern. The maximum jejunal caliber was normal ( 4 cm) in 7/13 (64%) and only mildly dilated (4-7 cm) in 4/13 (36%). No stomal ulcers have occurred. Over the past ten years this technique has been utilized in an additional 13 patients, again with no failure of the jejunum to reach the neck, loss of graft or operative mortality. Series of colon or stomach tube replacements with much shorter follow-up have uniformly reported no peristalsis in the segment. In addition, ulcers and other organ related problems have occurred and the incidence of these is likely to increase with time. In conclusion, when performed as a staged procedure, the jejunum can be reliably and safely utilized for esophageal replacement in children with excellent long-term functional results.

*By invitation

25. Eradication and Palliation of Squamous Cell Carcinoma of the Esophagus with Chemotherapy, Radiotherapy and Surgery

ZWI STEIGER* and ROBERT F. WILSON,

Detroit, Michigan

From April, 1977 through October 1980, 71 patients with squamous cell carcinoma (CA) of the esophagus were treated with pre-operative combined chemotherapy (CT) and radiotherapy (XRT). This consisted of (A) mitomycin-C (10 mg/M²) or cis-platinum (100 mg/M²) on days one and 21, (B) 5-fluorouracil (1000 mg/MVday) on days 1-4 and 29-32, and (C) 3000 rads days 1-5, 8-12, and 15-19.

In 29 patients, the therapy was primarily palliative because of poor medical condition (9), and bronchoesophageal fistula (8), distant metastases (7), and other prior malignancies (5). In all of these patients except two, the mucosal lesion disappeared with CT and XRT. The bronchoesophageal fistuli were managed surgically successfully with gastric bypass.

Six patients with potentially curable lesions refused surgery because of the excellent palliation with CT and XRT. Of 35 patients having surgery for potential cure after CT and XRT, 3(9%) died of post-op pulmonary complications. Ten patients (29%) had no histologic evidence of residual CA in the resected esophagus or lymph nodes. None of these patients have died or have recurrent CA esophagus; however, two have developed oropharyngeal CA. In another six patients (17%) only small microscopic islands of tumor cells were found in the resected esophagus. Of these six patients, none have recurrent esophageal CA but, one has developed oropharyngeal CA. Follow-up triple endoscopy in these patients is important.

*By invitation

26. Factors Affecting Response to Thymectomy for Myasthenia Gravis

JOSEPH W. RUBIN, ROBERTO. ELLISON,

HOLLAND V. MOORE* and GANESH P. PAI*,

Augusta, Georgia

Timing of surgery, thymic pathology, and immunological factors affect results of thymectomy for myasthenia gravis (MG). Review of hospital records of 97 patients with MG revealed 19 (14F, 5M) who had undergone thymectomy from 1961-1979. There were no surgical deaths. Pathologic examination recorded thymic hyperplasia in 10, no pathology in 5, involuted glands in 2, and thymoma in 1. Thymectomy resulted in 19%improvement: complete remission in 10, mild residual weakness in 5, and no change in 4. This study demonstrates that factors predictive of symptom amelioration were short duration of disease, thymic hyperplasia with abundant germinal centers, and acetylcholine receptor (AChR) antibodies present before and absent following complete transsternal thymectomy. Factors predictive of delayed or no response to thymectomy were long duration of disease before operation, thymic atrophy or no demonstrable pathology, incomplete excision and persistent AChR antibodies. Response was independent of sex and age. Our findings support the theory that the thymus in MG participates in the production of AChR antibodies which interfere with motor endplates and neuromuscular transmission causing myasthenic weakness. The autoimmunizing event is unknown. Excision of hyperplastic thymus early in the course of MG is associated with early remission. Prolonged postthymectomy impairment may be expected in some patients who have endured MG for years prior to surgery. Measurement of AChR antibodies routinely before and after thymectomy may yield valuable prognostic data and distinguish patients with active autoimmune disease possibly due to residual or regenerated thymus from those with endstage muscle weakness.

INTERMISSION - VISIT EXHIBITS

*By invitation

TUESDAY - MAY 12, 1981

4:00 P.M. Executive Session - International Ballroom

6:30 P.M. President's Reception - Corcoran Gallery of Art