TUESDAY AFTERNOON, April 30, 1985

2:00 p.m. Forum Session - Grand Ballroom

22. The Use of Muscle Flaps in the Repair of Aortic Defects

PETER J. HORNEFFER*, JAMES H. FRENCH*,

GROVER M. HUTCHINS* and TIMOTHY J. GARDNER

Baltimore, Maryland

Infection of an arterial anastomosis or prosthetic patch is an uncommon but devastating complication with few treatment options. The concept of bringing a fresh blood supply in the form of a muscle flap to help clear an infection is a well established surgical technique. When considering the use of a muscle flap for repair of an infected artery or graft, it must be established that striated muscle can withstand systemic arterial pressure and preserve vascular integrity. In the present study, 23 young pigs weighing 17 to 19 kg underwent left lateral thoracotomy under sterile conditions. Aortic defects 2 cm in diameter were created in the descending aorta just distal to the takeoff of the left subclavian artery. In one group (n = 11), this defect was patched with a freshly harvested but devascularized segment of chest wall muscle. In the second group (n = 12), the aortic defect was patched using a vascularized chest wall muscle flap.

Pigs from each group were sacrificed at three time intervals: within two weeks, at six weeks, and at 12 weeks postoperatively. There were no deaths or vascular complications in any pig which received a devascularized muscle patch. Muscle cells were necrotic as early as 3 days postop and an organized fibrinous pseudointimal layer had already begun to form. At six weeks, most of the muscle had been replaced by mature pseudointima, and by 12 weeks the psuedointima was of comparable thickness to the original arterial wall and contained smooth muscle-like elements. No aneurysmal changes were noted in any animal and the aortas maintained a normal lumen despite a tripling in mean body weight over the 12 week period. In the 12 pigs which received vascularized muscle flaps, overall flap viability at autopsy was 65%, but appeared to improve with surgical experience. There were two postoperative deaths at 4 and 6 weeks of apparent pseumonia and sepsis. The remaining animals sacrificed at 9 and 12 weeks had viable flaps overlying an organized psuedointima similar to the muscle patch recipients. In some, where the distal edge of the flap had died, vascular integrity was well maintained by pseudointima.

These results demonstrate that viable muscle flaps can be used to patch aortic defects and avoid the use of prosthetic materials in undesirable situations. The loss of flap viability appears to offer no threat to vascular integrity since free muscle patches, although undergoing cell necrosis and substantial remodeling, remain intact. These studies demonstrate at least the short term feasibility of this technique for use in patients for whom there is no other reliable approach.

*By Invitation

23. Concomitant Cardiac and Pulmonary Surgery

JEFFREY M. PIEHLER*, VICTOR F. TRASTEK*,

PETER C. PAIROLERO, JAMES R. PLUTH,

GORDON K. DANIELSON, HARTZELL V. SCHAFF*,

THOMAS A. ORSZULAK* and FRANCISCO J. PUGA

Rochester, Minnesota

Patients with surgical pathology of both the heart and lungs can be managed at one combined procedure or with staged operations. Although the combined approach through a single incision is theoretically advantageous in accelerating the definitive correction of both problems and eliminating a second procedure, little evaluation of such an approach can be found in the literature. From 1965 through 1983, 43 patients underwent concomitant cardiac and pulmonary procedures at our institution. Most patients presented with cardiac symptoms and were incidentally found to have a roentgenographically indeterminate lung nodule. The pulmonary diagnosis was unknown preoperatively in 38 patients (88%) and proved malignant in 9 of these (24%).All cardiac procedures required extra-corporeal circulation and included coronary bypass in 27 patients, valve replacement or repair in 12, correction of congenital anomalies in 2, and resection of myocardial tumor in 2. Pulmonary pathology proved benign in 31 patients, brochogenic carcinoma in 10, and metastatic carcinoma in 2. Concomitant pulmonary procedures were single wedge resections in 32 patients, lobectomy in 7, multiple wedge resection in 3, and pneumonectomy in 1. Most resections were performed either before or after institution of bypass, without systemic anticoagulation. There were no significant technical difficulties in performing the indicated resections via median sternotomy, and 9 of 10 resections for bronchogenic carcinoma were curative. Of the 2 operative deaths (4.6%), one was related to intra-parenchymal pulmonary hemorrhage after mutliple wedge resections with the patient heparinized. Thus, pulmonary resections performed during anticoagulation may be associated with increased risk and probably should be avoided. The second death was cardiac in origin and not related to pulmonary resection. The remaining patients recovered uneventfully. Definitive correction of both cardiac and pulmonary pathology can be performed at an operation via a single incision with safety and benefit to the carefully selected patient.

*By Invitation

24. Heart and Unilateral Lung Transplantation in the Dog

AKIRA KAWAGUCHI*, PAUL D. HIRSH*,

TIMOTHY C. WOLFGANG* and RICHARD R. LOWER

Richmond, Virginia

Chronic studies of heart-lung transplantation have been few because total cardiopulmonary denervation precludes prolonged survival in animals lower than primates. A procedure has been devised to study heart-lung transplantation in the dog employing orthotopic grafting of the heart and left lung, thereby preserving innervation of the autologous right lung to allow long term survival.

On cardiopulmonary bypass, the heart and left lung are excised preserving a pericardial pedicle. A heart-lung graft is implanted by anastomosing the left main bronchus with pericardiopexy, both atria, aorta and main pulmonary artery. All animals (n = 12) resumed normal respiratory pattern with prompt removal from respiratory support. This is in sharp contrast to dogs with total cardiopulmonary denervation who have erratic respiration insufficient to support life. With experience and cyclosporine immune-suppression, prolonged survival more than 24 hours (n = 8, 61%) up to 4 weeks has been obtained. Chronic serial studies have revealed normal ECGs, blood gases, chest X-rays and right heart catheterization pressures except during an episode of pulmonary reimplantation response.

The advantages of this canine model include: 1) its suitability for chronic studies of heart-lung transplantation, 2) it is less expensive than a primate model, and 3) the retained native lung serves as a control for evaluation of changes occuring in the lung allograft. If pericardiopexy or other procedures are successful in facilitating bronchial anastomotic healing, this procedure might have clinical application in selected cases.

*By Invitation

2:30 p.m. Scientific Session - Grand Ballroom

25. Surgical Management of Broncholithiasis

VICTOR F. TRASTEK*, PETER C. PAIROLERO,

ERIC L. CEITHAML*, JEFFREY M. PIEHLER*,

W. SPENCER PAYNE and PHILIP E. BERNATZ

Rochester, Minnesota

Fifty-two patients (31 male and 21 female) underwent surgical treatment for complications of broncholithiasis between 1969 and 1983. Mean age was 50.8 years (range 27 to 74 years). Indication for operation included symptoms in 49 patients and an abnormal chest x-ray suggestive of tumor in 3. Symptoms included cough in 47 patients, hemoptysis in 30, fever in 18, chest pain in 11, and lithoptysis in 10. Forty patients were initially treated by thoracotomy and 12 by bronchoscopy alone. In the group treated by thoracotomy, pulmonary resection was performed in 34 patients and broncholithectomy in 6. There was 1 operative death (2.5%). Significant complications, including postoperative bleeding, vocal cord paralysis, and esophageal leak, occurred in 4 patients (10.3%). In the group treated by bronchoscopy, broncholithectomy was successful in 8 patients (75%). Significant complications, including bronchial bleeding and bronchial tear, occurred in 2 patients. There were no deaths. In the 4 unsuccessfully treated patients, subsequent thoractomy to remove the broncholith was necessary in 3. Follow-up was available in 50 patients and averaged 76.5 months (range 6 to 183 months). Overall 15-year survival (Kaplan-Meier) was 75.1% and did not differ from a control group of patients matched for age and sex. Thirty-three patients following thoracotomy are alive and well without evidence of recurrent disease. Four patients have died from causes unrelated to their procedure or broncholithiasis. In contrast, broncholithiasis recurred in 3 patients (37.5%) who were initially treated successfully by bronchoscopy. Subsequent thoracotomy was necessary in 1 of these patients, and broncholithiasis was responsible for 1 of 2 late deaths. We conclude that thoracotomy remains the preferred treatment for patients with complications of broncholithiasis, as the risks remain low and the long-term results are excellent.

*By Invitation

26. Wedge Resection as an Alternative Procedure for Peripheral Bronchogenic Carcinomas in Poor Risk Patients

LEE E. ERRETT*, JAMES WILSON*, RAY C.-J. CHIU

and DARRELL D. MUNRO

Montreal, Quebec, Canada

Although lobectomy is the procedure of preference for patients with peripheral, clinical stage I bronchogenic carcinomas, wedge resection of the tumor may be a satisfactory alternative in poor risk patients.

Between 1970 and July 1982, 190 patients with peripheral bronchogenic carcinomas were operated upon. Clinical staging was established by radiography, bronchoscopy and mediastinoscopy. Ninety-three patients underwent lobectomies, while 97 had wedge resections. The decision to perform wedge resection was made pre-operatively in the majority of cases based on the assessment of their operative risks.

Compared to lobectomy patients, those who had wedge resections were older (70.4 ± 4.6 years versus 64.9 ±4.9; P<0.001), with lower pre-op FEV, (1.56 ± 0.29 versus 1.94 ± 0.24; P<0.001), lower PaO₂ (71.7 ± 8.2 mmHg versus 76 ± 4.8; P<0.001) and higher PaCO₂ (42 ± 3.6 mmHg versus 38 ± 4.4; P<0.001). In spite of more severely compromised pre-op respiratory functional status, the wedge resection group had 30 day operative mortality and morbidity comparable to those of the lobectomy group (3.1 versus 2.2% and 12 versus 9%, respectively). Our follow-up results at 24 months showed that the absolute survival rate of 66.5% in the older, poor risk wedge resection group is not statistically significantly different (P = 0.5) from 74.9% for the lobectomy patients.

Wedge resection can be carried out faster, with the loss of lesser amount of functional pulmonary tissue. It appears, therefore, by performing wedge resection in selected poor risk patients, one can reduce the operative mortality and morbidity to an acceptable range, without seriously compromising their long term survival.

3:15 p.m. Intermission - Visit Exhibits - Grand Salon

Complimentary Coffee

*By Invitation

3:45 p.m. Scientific Session - Grand Ballroom

27. Cyclosporine: An Immunosuppressive Panacea?

JACK G. COPELAND, MARK M. LEVINSON*,

JAMES K. FULLER*, JANICE A. COPELAND*,

MARY JEAN McALEER* and ROBERT W. EMERY*

Tucson, Arizona

From January 1, 1983 through October 31, 1984, 26 patients, age 16 to 57 years, have undergone cardiac transplantation utilizing Cyclosporine/-Prednisone (CsA/P) immunosuppression. Five patients died ≤ 90 days (20%) of infection (3), renal failure (1), and severe rejection (1). One patient died at 4 months of diffuse lymphoma. These patients are compared to a similar group of 32 cardiac recipients, age 13 to 52 years, with Imuran/Prednisone (I/P) immunosuppression:

Rejection episodes occurred in 21/26 CsA/P patients, the average onset of the first on the 8th post-transplant day. Two patients (8%) developed postoperative mediastinitis, both survived. Of 17 patients surviving ≥ 90 days, there has been one late rejection episode, occurring 16 mos. post-transplantation, and two patients have required hospitalization for the treatment of opportunistic infections (Herpes Zoster -1; nocardia -1). One patient underwent cholecystectomy, one highly selective vagotomy and cholecystectomy, and one appendectomy, 7 months, 6 months, and 4 months respectively post-transplantation without complications. One year cardiac catheterization performed in 5 patients revealed normal coronary anatomy, intra cardiac pressures and ejection fractions. Late renal failure has not occurred, however, at one year renal function tests (BUN = 32 ± 10; Creatinine = 1.8 ± 0.5) are elevated. We conclude that while survival and rejection and infection episodes are similar between I/P and CsA/P groups, these events are more easily controlled in the CsA/P patients. Hospital time and its intercurrent costs are reduced. CsA/P is currently the immunosuppressive agent of choice in patients undergoing cardiac transplantation.

*By Invitation

28. Management of Benign and Malignant Lesions of the Trachea and Bronchi with the ND-YAG Laser

WALTER G. WOLFE and DAVID C. SABISTON, JR.

Durham, North Carolina

The neodymium-YAG (yttrium-aluminum-garnet) laser is basically different from other lasers in that the argon and carbon dioxide lasers are dependent upon generation of heat and the thermal coagulation produced may be absorbed by the surrounding tissues. However, the Nd-YAG laser is based upon another mechanism which produces a shorter energy pulse with a much higher peak power and creates an ionized cloud of particles with little heat dissipation to surrounding structures.

This report consists of a series of 32 patients with lesions of the trachea or bronchi. Thirty patients have presented with advanced carcinoma of the lung with pulmonary infection or abscess distal to an obstructing bronchial lesion or with hemoptysis. Benign strictures have been seen in 2 patients. A total of 52 laser treatments have been administered, 42 primarily for obstruction and 10 for hemoptysis. There was no significant morbidity and only one hospital death unrelated to the laser therapy. Most patients' hospital stay was limited to a single day.

Among the 30 patients with malignancy, obstructive complications and hemoptysis were successfully controlled in 27. Those with benign lesions have been successfully managed by laser therapy. Presently 20 patients in the malignant group remain alive and are symptomatically improved. The longest survival after successful laser treatment has been 69 weeks and the shortest 12 weeks.

In summary, the YAG laser is a very effective means of managing patients with benign lesions and those with advanced carcinoma of the lung and severe hemoptysis or infection distal to occluding lesions in the trachea or main stem bronchus. The latter group obtain very favorable palliation with this mode of therapy.

*By Invitation

29. The Role of Adjuvant Therapy Following Resection of Modified Stage II Lung Cancer

MARK K. FERGUSON*, RO YBEVERIDGE*,

ALEX G. LITTLE*, HARVEY M. GOLOMB*,

TOM R. DEMEESTER, PHILLIP C. HOFFMAN

and DAVID B. SKINNER Chicago, Illinois

From 1974 through 1984, 36 consecutive patients with modified Stage II (T₁N₁M₀ or T₂N₁M₀) non-small cell lung cancer were evaluated and treated. Six patients had T, tumors, 29 had T₂ tumors and in one patient the size of the primary was not available. There were 25 males and 11 femals aged 38 to 80 years (mean 64.1 years). Nineteen patients had adenocarcinoma, 13 had squamous histology and 4 had large cell cancers. Two patients had radiation therapy as their sole treatment and are not considered further. Resection was performed in 34 patients, 16 by pneumonectomy and 18 by lobectomy, with two operative deaths. Nine patients received no additional treatment. Seven patients (SR) had resection followed by postoperative mediastinal radiation therapy only (3000 cGy). Sixteen resected patients (SRC) had adjuvant mediastinal radiation therapy (3000 cGy) and chemotherapy (cytoxan, adriamycin,, methotrexate and procarbazine for an average of 10 cycles). Median survival for all patients was 18.5 months. Surgical treatment alone yielded a median survival of 11.5 months (p = .055 vs SR, p=.004 vs SRC) with one patient currently alive. Resection combined with radiation therapy produced a 19.2 month median survival (p=.19 vs SRC) with 2 patients alive. For patients treated with the combination of surgery, radiation therapy and chemotherapy the median survival was 45.3 months with 8 patients currently alive. Survival was unrelated to cell type, size of the primary tumor, presence or absence of visceral pleural involvement, distance of the tumor from the resected margin, the number of nodes involved, or the type of resection performed. There were 14 documented recurrences, of which only one was local, while 6 occurred in the brain. Of 21 deaths other than operative mortalities, 13 were due to progressive disease.

The data indicate that adjuvant treatment, consisting of radiation therapy and chemotherapy, provides significantly prolonged median survival following resection of modified Stage II non-small cell lung cancers. Nevertheless, there is a high rate of relapse at distant sites which necessitates careful follow-up of these patients and suggests the need for improved modes of adjuvant therapy.

AN HISTORICAL VIGNETTE

LYMAN A. BREWER, III

Pasadena, California

5:00 p.m. Executive Session (Members Only) - Grand Ballroom

7:00 p.m. President's Reception - Grand Ballroom

Tickets Required

*By Invitation