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 At six weeks, most of the muscle had been replaced by mature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:
|
|
Actuarial
Survival
(3 mo.)
|
Actuarial
Survival
(1 yr.)
|
Infections
(3 mo.)
|
Rejections
(3 mo.)
|
Hospital Stay
(Average)
|
|
CsA/P
|
79%
|
74%
|
0.9/Pt
|
1 .4/Pt
|
26 Days
|
|
I/P
|
78%
|
66%
|
1 .0/Pt
|
1.6/Pt
|
62 Days
|
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
