American Association for

Thoracic Surgery

62ND ANNUAL MEETING

Scientific Program

MONDAY MORNING, MAY 3, 1982

8:30 a.m. Business Session (Limited to Members)

Assembly Hall

8:45 a.m. Scientific Session - Assembly Hall

1. Surgical Resection In the Management of Small Cell Carcinoma of the Lung

THOMAS W. SHIELDS, GEORGE A. HIGGINS, JR.*,

MARY J. MATTHEWS* and ROBERT J. KEEHN*,

Chicago, Illinois and Washington, D. C.

To define the role of initial surgical resection in patients with undifferentiated small cell carcinoma of the lung (SCLC), the experience of a cooperative surgical group has been reviewed. One hundred forty-eight patients with SCLS have undergone a microscopically curative resection. This represents 4.7% of "curative" resections carried out in four major prospective adjuvant chemotherapy trials. In the early trials (101 patients), 16 patients (15.8%) died within the first 30 postoperative days. In the last trial, 8 of the patients still alive have been so less than 5 years. These two groups of patients have been excluded from the determinate group. Of the 124 determinate patients, 101 have died of their disease prior to the fifth anniversary of the operation and 23 had survived beyond this point (18.5%). The tumor of each was classified pathologically by the TNM system. The 5-year survival of each category was: T,N₀M₀, 45.8%; T,N,M₀, 28.5%; T₂N₀M₀, 20.0%; T_;N,Mo, 7.8%; any T, or N₂, 3.5%.

The effect of postoperative adjuvant chemotherapy was evaluated in each of the trials. No beneficial effect of the adjuvant therapy was noted with a one course regimen of a single drug but possible benefit, although not significant, was noted in a prolonged intermittent chemotherapy trial. In the most recent trial of prolonged intermittent courses of two drugs, a two year survival of 80.8% was noted in those receiving adjuvant chemotherapy as compared to a 58.7% in the control group.

It is concluded that resection is indicated in the patients with T₁N₀M₀ lesions. Patients with T₁N₀M₀ lesions or T₂N₀M₀ lesions also probably should be resected. Intensive postoperative chemotherapy appears indicated. Whether or not prophylactic cranial irradiation is indicated has not been addressed. Primary surgical resection is contraindicated in patients with any oilier TNM classification.

*By Invitation

2. Influence of Histology on Survival After Curative Resection for Undifferentiated Lung Cancer

JOHN E. MAYER, JR. *, STEPHEN L. EWING*,

JAN OPHOVAN*. HATTON W. SUMNER* and

EDWARD W. HUMPHREY, Keeler AFB,

Mississippi; Minneapolis and St. Paul, Minnesota

Undifferentiated carcinoma of the lung carries a worse prognosis overall than other cell types, but it is unclear whether these tumors represent a homogenous group with uniformly poor survival. This study identifies certain histologic sub-types of large cell (LCC) and small cell (SCC) undifferen-tiated carcinoma which have a better prognosis after curative resection than other similarly treated Undifferentiated carcinomas. From 1950 thru 1975, 2352 patients with lung cancer were admitted to one hospital. Follow-up to death was available in all but 66 patients. Pathologic material was reviewed from 1979 cases by a team of three pathologists during a single six-month period without knowledge of clinical outcome. Curative resection was carried out in 632 with 170 (27%) 5 year survivors. SC cancer occurred in 551 patients and 7 (1.3%) survived 5 years. Curative resections were performed in 33 with polygonal SCC, 19 with negative lymph nodes (LNN) and 14 with positive lymph nodes (LNP). Seven survived 5 years (21%), 6/19 LNN and 1/14 LNP. Twelve with non-polygonal SCC (9 oatcell, 3 fusiform) (6 LNN, 6 LNP) underwent curative resection with no survivors. (X² = 2.94 .05 < p < . 10) LCC occurred in 151 and 16 survived 5 years. Curative resection was performed in 22 having LCC with stratification (14 LNN, 8 LNP) and 11 (50%) survived 5 years. In 26 with non-stratified LCC undergoing curative resection (19 LNN, 7 LNP) 5 (19%) survived 5 years (X² = 5.08 p<.05). Thus, patients with resectable polygonal SCC have a better prognosis than those with non-polygonal SCC, and their prognosis approaches that of all patients with resectable lung cancer. Resectable patients having LCC with stratification have a significantly better prognosis than those with non-stratified LCC. Patients with these sub types should therefore not be denied an attempt at curative resection because of the diagnosis of Undifferentiated lung cancer.

*By invitation

3. Survival in Patients Undergoing Tracheal Sleeve Pneumonectomy for Bronchogenic Carcinoma

ROBERT J. JENSIK, L. PENFIELD FABER,

ROBERT W. MILEY*, W. CRAIG THATCHER*

and NABIL M.I. ELBAZ*. Chicago, Illinois

and Fort Worth, Texas

Thirty-four patients (1964 through 1981) have undergone tracheal sleeve pneumonectomy for carcinoma of the lung in whom the malignancy has extended proximally to involve the orifice of the stem bronchus or the lateral aspect of the lower trachea.

Simultaneous lung, carinal, and lower tracheal resection with anastomosis between trachea and left main bronchus was performed in 30 patients. In 4 patients pneumonectomy had been done previously and because of recurrence in the stump, (2 on the right and 2 on the left) carinal resection and tracheo-bronchial anastomosis was carried out.

Radiation therapy was administered preoperatively to 28 patients in the series and was considered to be of major benefit in reducing the volume of the tumor to permit the surgical procedure.

Three patients have survived over 10 years and one lived approximately 9 years and 11 months. One is alive over 6 years, and of those dying before the 5-year period, 3 survived between 2 and 3'/2 years and 4 between one and 2 years.

The most common complication was fistula occurring at the anastomosis, developing in 5 of the 11 patients who died in the post-operative period (32% mortality). In all of these radiation had been given preoperatively.

In the last 4 cases, high frequency jet anesthesia was utilized which greatly simplified the anastomosis while maintaining ventilation through a 2 mm. catheter. Although one patient developed a fistula, it was small and successfully controlled by re-operation and application of an intercostal muscle pedicle.

The long-term survival achieved in 5 patients (15%) in whom the future is practically hopeless is justification in carrying out tracheal sleeve resection.

*By invitation

4. Mini-Thoracotomy With Chest Tube Insertion for Children With Empyema

JOHN G. RAFFENSPERGER, SUSAN R. LUCK*

and RICHARD R. RICKETTS*, Chicago, Illinois

and Atlanta, Georgia

Empyema in children has become a rare disease since the staphylococcal epidemic during the 1950s. However, empyema continues to be an unusual complication of pneumococcal, staphylococcal and hemophilus pneumonia. When the initial pneumonia is inadequately treated with antibiotics, a pleural effusion forms which, if unrecognized, becomes thickened with fibrinous material. An early empyema may be treated with thoracentesis or the closed chest insertion of a chest tube. Either of these procedures are useless if the pus is thick and loculated. Furthermore, the insertion of a chest tube into a crying, stubborn child can be frustrating for the surgeon and painful for the patient.

We now perform a "mini-Thoracotomy" under general anesthesia. The area of suspected empyema is marked on the surface of the chest. We then make a small incision and resect a short segment of rib. The incision is only large enough to insert one or two fingers and a suction tip in order to break up loculations and to remove thick, fibrinous material. The pleural cavity is lavaged with an antibiotic solution and the chest tube is placed under direct vision in a suitable location. The wound is then closed and the tube is placed on suction. With this procedure complete drainage is quickly and easily obtained, the lung expands rapidly, and hospitalization is shortened. We have used this procedure in 15 infants and children during the past 10 years.

10:15 a.m. Intermission - Visit Exhibits

*By invitation

11:00 a.m. Scientific Session - Assembly Hall

5. The Hemodynamic Effects of Protamine Infusion Following Cardiopulmonary Bypass

NADIV SHAPIRA*, HARTZELL V. SCHAFF*,

JEFFREY M. PIEHLER*, JOHN C. SILL*,

ROGER H. WHITE* and JAMES R. PLUTH,

Rochester, Minnesota

Systemic hypotension is commonly observed in association with the administration of Protamine (P) after cardiopulmonary bypass (CPB). Previous studies are inconclusive as to whether P produces its effect on myocardial performance or by changing systemic vascular resistance.

To elucidate the hemodynamic effects of P (150 mg x body surface area), 19 patients were studied following CPB. In one group (n =7) P was infused over 30 sec while in a second group (n = 6) over 60 sec. A third group (n = 6) received CaCl₂ (20 mg/kg over 10 min) just prior to P administration. The hemodynamic response was assessed by continuous recording of myocardial contractile element velocity (maximal value = Vpm, Millar transducer), aortic blood flow (electromagnetic flowmeter), systemic and pulmonary arterial and right atrial pressures, and EKO. The response in each group was analyzed by t-test for paired data and the groups were compared by two sample t-tests. Results (mean ± SD) are summarized below:

	30 sec		60 sec/no Ca		60 sec with Ca
	Control	Response	Control	Response	Control	Response
Vpm (sec-1)	13.6 ± 3.6	11.9 ± 2.6	12.2 ± 3.0	11.5 ± 2.9	11.9 ± 2.1	11.1 ± 2.6
Mean BP (mmHg)	82 ± 9	54 ± 18*	77 ± 9	63 ± 11	90 ± 18	79 ± 23*
Cardiac Index
(L/min/m2)	3.2 ± .52	3.8 ± .61*	3.4 ± .96	3.7 ± .96*	2.6 ± 1.0	2.9 ± .97*
Systemic Vascular	6.8 ± 2.7	4. 8 ± 2. 9*	5.5 ± 1.6	4.0 ± 1.5*	11.0 ± 6.1	7.9 ± 4.2
Resistance Index
(U/m2)	(*P < .05 vs control)

The response to P among the three groups was not different.

These results demonstrate that the P induced hypotension is the result of peripheral vasodilation only partially compensated by an increase in CI, whereas myocardial contractile state remained unchanged. These changes are transient (less than 4 min), unrelated to the rate of administration and not prevented by preinfusion of CaCl₂.

*By invitation

6. Experience With Profound Hypothermia and Circulatory Arrest In the Treatment of Aneurysms of the Aortic Arch

M. ARISAN ERGIN*, JAMES O'CONNOR*,

ROY GUINTO* and RANDALL B. CRIEPP,

Brooklyn, New York

Resection and replacement of the aortic arch represents a demanding technical and tactical challenge to the surgeon. Circulatory arrest during the period of arch exclusion with preservation of central nervous system integrity by profound total body hypothermia renders this procedure simple and safe.

In a series of 19 consecutive patients, the aortic arch and varying portions of ascending and descending aorta, and in some, the aortic valve were replaced utilizing a standard method of profound total body hypothermia. Thirteen patients underwent elective and 6 patients emergency arch replacement. A combination of surface cooling and cardiopulmonary bypass was used to produce total body hypothermia. Replacement of the aortic arch was carried out during a single period of circulatory arrest. Cardiopulmonary bypass was utilized for core rewarming. The average cerebral ischemia time was 39 minutes (range 15-59 minutes) at an average core temperature of 13°C (range 11-18°C). The average myocardial ischemia time was 73 minutes (range 40-110 minutes) with an average duration of cardiopulmonary bypass of 124 minutes (range 85-201 minutes).

Of the 13 patients undergoing elective operation, 2 died; of the 6 patients undergoing emergency operations, 3 died (2 with ruptured aneurysms, 1 with acute arch dissection). Fourteen patients are alive and well 2 months to 7 years following surgery. All are free of neurological sequalae. One has an asymptomatic residual dissection in the descending aorta.

This experience indicates that profound total body hypothermia with cirulatory arrest is a safe and effective method for elective surgical treatment of enlarging aneurysms of the aortic arch and for emergency treatment of acute dissections where the intimal tear is located in the aortic arch. The technique is simple and produces results superior to those reported for methods which involve selective cerebral perfusion during arch replacement.

11:30 a.m. Presidential Address

The Crisis of Excellence

Thomas B. Ferguson

*By invitation