WEDNESDAY MORNING, May 1, 1985

8:30 a.m. Scientific Session - Grand Ballroom

30. Chest Wall Tumors: Experience with 100 Consecutive Cases

PETER C. PAIROLERO AND PHILLIP G. ARNOLD*

Rochester, Minnesota

One hundred consecutive patients (55 female and 45 male) with chest wall (CW) tumor underwent CW resection between October 1976 and November 1984. Ages ranged from 18 to 84 years (median 54.5 years). Fifty patients had primary tumor, 32 had metastatic tumor, and 18 had benign tumor. The tumor had been previously resected in 34 patients and irradiated in 18. Twenty-two patients presented with skin ulceration. Location was in the ribs in 78 patients and in the sternum in 22. Average number of ribs resected ranged from 1 to 8 (median 3.4). Sternectomy was performed in 22 patients. Overlying soft tissue was resected en bloc in 45 patients. Reconstruction was with autogenous tissue alone in 46 patients and with prosthetic material in 54. There were 100 muscle transpositions, including 45 pectoralis major, 33 latissimus dorsi, 9 serratus anterior, and 13 others. Free rib grafts were used in 11 patients and omental transposition in 3. Hospitalization ranged from 4 to 80 days (median 9.6 days). Complications occurred in 9 patients and included wound infections in 5, partial flap loss in 5, and respiratory insufficiency in 4. One patient required tracheostomy. There was 1 operative death. Follow-up ranged from 1 to 91 months (median 31.5 months). Ninety-eight patients had a healed CW. Recurrent CW tumor developed in 7 patients. All patients with benign tumor and 94.2% of patients with primary tumor not previously treated were alive. However, only 41% of patients with metastatic tumor and 38% of patients with previously treated primary CW tumors were alive. Metastases were responsible for 90% of deaths. We conclude that aggressive resection for CW tumor with reliable reconstruction can be accomplished safely and that early wide resection is potentially curative treatment.

*By Invitation

31. Modern Management of Adult Thoracic Empyema

JOHN H. LEMMER*, MARK J. BOTHAM*

and MARK B. ORRINGER

Ann Arbor, Michigan

Seventy adult patients with thoracic empyema were treated between 1978 and 1982. Twenty-one (30%) of these empyemas were associated with pneumonia, 25 (36%) occurred as postoperative complications, and 7 (10%) were iatrogenic, developing after thoracentesis of sterile pleural effusions. Standard thoracentesis was performed in 50 patients and was diagnostic in 38 (76%). In seven additional patients, diagnostic thoracentesis was performed after localizing the empyema with either ultrasound, fluoroscopy, or chest CT scan. Bacteriologic cultures were positive in 94% of these patients, and anaerobes were present in 26%. When used as the initial mode of therapy, repeat thoracentesis was successful in only 4 of 11 cases (36%). Similarly, closed tube thoracostomy, as initial treatment, was successful in only 14 of 40 cases (35%). Eight of 12 patients (67%) with parapneumonic empyemas were treated successfully with closed tube thoracostomy, in contrast to only 2 of 17 patients (12%) with postoperative empyemas so treated. Overall, rib resection was performed 22 times, thoracoplasty 7 times, and thoracotomy with decortification 4 times. Control or cure of empyema was achieved in 57 patients (81%), while 13 (19%) died (5 from their empyema and 8 with empyema as an active problem at the time of death). The cure/control rate for immuno-suppressed patients was only 50% (5 of 10 patients). This analysis of a large recent series of adult empyemas suggests that chest tube drainage is often inadequate, and more aggressive management is likely to result in fewer treatment failures, fewer total procedures and shortened hospital stay. Early rib resection, especially for immunocompromised patients and postoperative empyemas, is recommended.

*By Invitation

32. Surgical Management of the Failed Gastroplasty Operation

ROBERTO. HENDERSON

Toronto, Ontario, Canada

Gastroplasty has been used in surgical management of reflux for 25 years. The creation of a gastric tube prior to fundoplication complicates further corrective surgery, should the original operation fail. Experience has been gained with 51 patients, 34 partial fundoplication gastroplasties (PFG: Belsey) and 17 with total fundoplication (TFG: Nissen) who have major persistent or recurrent symptoms. All were evaluated by history, radiology, endoscopy, manometry with pH and acid perfusion prior to surgical management. The PFG patients had heartburn (85%), reflux (70%) and dysphagia (91%). Radiologic recurrence was present in 26.5%, endoscopic incompetence in 94.1% and a stricture in 26.5%. TFG patients had heartburn (52.9%), reflux (29.4%) and dysphagia (82.4%). Radiologic recurrence was present in 29.4%, endoscopic incompetence in 35.3% and a stricture in 5.9%. On average these patients had had 2.3 prior operations (range 1-5 operations). The dominant cause of failure (in the absence of anatomic recurrence) with PFG was continued or recurrent reflux and with TFG was too tight or too long a fundoplication. All patients had a thoraco-abdominal revision TFG and a 1 cm. completion fundoplication. Pyloro-myotomy was added if not previously performed. There was no mortality or major morbidity. Follow-up in 51 patients averages 4.2 years (range 0.3-8.8 years). None have radiologic recurrence, 1 minor reflux, 1 a traumatic diverticulum and 1 moderate esophageal obstruction. Of these patients 82.4% are asymptomatic, 13.7% have minor symptoms and 3.9% (2 patients) have significant residual symptoms. This conservative surgical approach avoids the higher mortality of resection with interposition and the results are satisfactory.

*By Invitation

33. Transhiatal Esophagectomy for Benign Disease

MARK B. ORRINGER

Ann Arbor, Michigan

During the past 8 years, transhiatal esophagectomy without thoracotomy has been performed in 65 adult patients with dysphagia from benign esophageal disease: strictures (from reflux in 8, caustic ingestion in 7, and other causes in 15); neuromotor dysfunction (Achalasia in 12, spasm in 9, scleroderma in 3); acute iatrogenic perforation (5); acute caustic injury (4); and recurrent gastroesophageal reflux (2). Nearly 70% (45) of these patients had undergone at least one prior esophageal operation, and 26% (17) had a history of between 2 and 4 esophageal operations. The esophagus was replaced with stomach in 53 pts (82%). Colon was used to replace the esophagus in 10 pts and only when there was a history of either prior gastric resection or caustic injury to the stomach. Intraoperative blood loss averaged 1050 cc. Intraoperative complications included pneumothorax in 38 pts (58%) and a tracheal laceration (1 pt). Postoperative complications included transient recurrent laryngeal nerve paresis in 11 pts (17%); chlothorax in 4 pts (6%); anastomotic leak in 4 pts (6%); and small bowel obstruction (2 pts). There were 5 hospital deaths (8% mortality), none related to the technique of esophagectomy. Follow-up ranges from 1 to 84 months (avg. 28 months). Thirty patients have experienced varying degrees of postoperative dysphagia, and 22 have been treated with intermittent outpatient anastomotic dilations. True anastomotic strictures have developed in 5 pts. The ability to eat foods of a normal consistency has been excellent in 56 pts. Four patients with initial esophageal spasm have had poor functional results from esophagectomy and visceral esophageal substitution. Occasional mild regurgitation has been expeienced by 12 pts, and post-vagotomy diarrhea (dumping) by 16 pts. It is concluded that transhiatal esophagectomy for benign disease is feasible and safe, even after multiple previous esophageal operations, and that the stomach is a better visceral esophageal substitute than colon, providing an initially easier technical operation and long-term superior functional results.

10:00 a.m. Intermission - Visit Exhibits - Grand Salon

Complimentary Coffee

*By Invitation

10:45 a.m. Scientific Session - Grand Ballroom

34. Anatomic Correction for Transposition of the Great Arteries and Double Outlet Right Ventricle

KIRK KANTER*, MICHAEL RIGBY*,

ELLIOTT SHINEBOURNE*

and CHRISTOPHER LINCOLN*

London, England

Sponsored by: J. W. KIRKLIN

Birmingham, Alabama

Since October, 1981, 27 patients have undergone anatomic correction for a spectrum of complex CHD. Eight pts had transposition of the great arteries with intact ventricular septum and patent ductus arteriosus (TGA/-PDA), 13 pts transposition with ventricular septal defect (TGA/VSD), and 6 pts double outlet right ventricle with subpulmonary VSD (DORV), the Taussig-Bing anomaly. At operation, the age ranged from 18 hrs to 6 yrs (mean 9.4 mos) and the weight ranged from 2.6-14.6 kg (mean 5.6 kg). The TGA/PDA group on average was younger (mean 1.2 mos) and smaller (mean 3.5 kg) than the other two groups. Associated congenital heart defects were seen in 7 pts, including 5 with coarctation, 2 with multiple VSD's, 2 with right ventricular hypoplasia and one each with interrupted aortic arch, Wolff-Parkinson-White syndrome, and left juxta position of the atrial appendages. All 9 pts who had undergone prior palliative surgery had pulmonary artery banding. In addition, four of these pts had coarctation repairs, 4 had atrial septectomy and one had systemic/pulmonary shunting. All recognized patterns of coronary anatomy were encountered. The aorta and pulmonary artery were side-by-side in 13 pts and anterio-posterior in 14 pts. The Le Compte maneuver to establish right ventricular pulmonary artery continuity was successfully used in 13 of 14 pts with antero-posterior great vessels but in only one of those with side-by-side relations. Six pts developed right ventricular outflow tract obstruction, 5 at operation and one 4 months postoperatively. This was responsible for death in 3 pts. Thirty day hospital mortality was one in TGA/PDA (12.5%), 6 in TGA/VSD (46%) and one in DORV (16.7%); overall mortality 8 pts (29.6%). There has been only one death in the last ten patients.

There have been no late deaths up to 3 years follow-up. Postoperative angiograms in ten pts with frame by frame analysis of left ventricular wall motion shows normal ejection fraction and satisfactory regional wall movement.

*By Invitation

35. Ninety Consecutive Corrective Surgeries for Tetralogy of Fallot With or Without Minimal Right Ventriculotomy

YASUNARU KAWASHIMA *, HAJIME HIROSE*,

HIKARU MATSUDA*, SUSUMU NAKANO*,

RYOTA SHIRAKURA * and JUNJIRO KOBAYASHI*

Osaka, Japan

Sponsored by: HITOSHI MOHRI Yamaguchi, Japan

Out of 90 consecutive patients (pts) who underwent corrective surgery for tetralogy of Fallot (TF), 43 pts were operated upon without right ven-triculotomy and 47 pts had a minimal right ventriculotomy of about 10 to 15 mm in length. The ventricular septal defect was closed through the tri-cuspid valve in 75 pts. The pulmonary valve was either preserved or reconstructed to maintain its competence. Fifty-one pts were either one or two years of age.

There was one operative death and no late mortalities. Results of postoperative cardiac catheterization and cine angiocardiography, performed in 34 randomly selected pts, were compared with those of 21 pts who had undergone conventional method of surgery in the preceding period. The following results were found: 1) There was no significant difference in the right ventricular to left ventricular systolic pressure ratio (0.46 ± .15 vs. 0.44 ± 0.13). 2) Pulmonary regurgitation (Grade 2/4 or more) was found in 47% (16/34) of the present series of pts (P-pts) and 81% (17/21) of the controls (C-pts) (p<0.05). 3) There was no significant difference between the two groups in cardiac index (4.38 ± 0.88 vs. 4.20 ± 1.18L/min/m²) or right ventricular ejection fraction (RVEF) 53 ± 6 vs. 50 ± 5%). However, during isoproterenol infusion, accelerating the heart rate by 50%, the RVEF was significantly higher in P-pts (57 ± 4%) than in C-pts (49 ± 6%) (p<0.001). The right ventricular end-diastolic volume index was significantly smaller in P-pts than in C-pts both at rest (81 ± 21 vs. 109 ± 30ml/m²:p<0.01) and during isoproterenol infusion (91 ± 37 vs. 142 ± 28ml/m²:p<0.01).

A Grade 2 or higher ventricular arrhythmia defined by Lown's criteria was found in 17% (6/35) of P-pts and in 54% (35/65) of C-pts. The difference was statistically significant (P<0.005).

Thus, the present method of corrective surgery for TF carries no more risk than the conventional method and the results were more favorable in respect to postoperative right ventricular function.

*By Invitation

36. Definitive Surgery for Refractory Cardiac Tachydysrhythmias in Children

DAVID A. OTT, ARTHUR CARSON*

and DENTON A. COOLEY

Houston, Texas

105 children (age range 4 months-18 years) underwent definitive surgery for life threatening or incessant tachydysrhythmia due to accessory conduction pathways (Kent bundle) (75), atrial ectopic foci (18) or ventricular ectopic foci (12). 64% (48/75) of patients with the accessory pathway type of supraventricular tachycardia had classical Wolff-Parkinson-White syndrome whereas 36% (27/75) had retrograde conduction only across the pathway. Location of the pathways were as follows: left posterior 46% (35/75), right anterior or lateral 29.3% (22/75), posterior septal 17.3% (13/75), anterior septal 4% (3/75), both right and left 2.7% (2/75). With increasing experience the success rate (cure of tachycardia) had improved from 85% in the first 40 patients to 96% of the last 35 patients. One surgical death (1.3%) occurred secondary to a paradoxical air embolus. Atrial ectopic tachycardia was treated by cryoablation (9), excision (1), combined excision and cryoablation (6), and atrial disconnection (2). The ectopic focus was located on the right atrial wall in 12 patients (66%) and cardiopulmonary bypass was required in 9 (50%). Two patients (11.1%) continued to have tachycardia after surgery. Ventricular tachycardia presenting in the first 2 years of life was due to tumor in 5 cases (rhabdo-myoma 1, Purkinje cell tumor 4) and was treated by excision and cryoablation. In 4 cases no tumor was found but the area of ectopic focus was successfully cryoablated. One child with diffuse endocardia! tumor died following surgery. Ventricular tachycardia in older children was localized to outflow patch aneurysms following Tetralogy of Fallot repair (3 patients, treated by excision or cryoablation) and arrhythmogenic right ventricular dysplasia (2 patients, treated by right ventricular disconnection).

We conclude that mapping and surgery for supraventricular tachycardia due to accessory pathways is predictable and curative in a high percentage of patients. Atrial ectopic tachycardias are more difficult to precisely localize but can be cured by a combination of excisional and cryoablative techniques. Ventricular tachycardia in infants is commonly due to tumors for which surgery can be a lifesaving procedure.

*By Invitation

37. Diaphragmatic Paralysis and Eventration in Infants

ROBERT M. SADE, CHARLES D. SMITH*,

FRED A. CRAWFORD*, H. BIEMANN OTHERSEN*

and DAVID M. BARTLES*

Charleston, South Carolina

Diaphragmatic malfunction in small babies can interfere substantially with ventilation. Since 1979, we have diagnosed 27 infants (9 boys, 18 girls) as having either diaphragmatic paralysis or eventration at 1 day to 15 months of age. A congenital phrenic lesion (CPL) was found in 13 patients (pts), and 14 (all newborns ≤ 3 months old) had an operative phrenic nerve injury (OPNI). Respiratory distress was present in 19 pts and not present in 8. Diaphragmatic plication (DP) was carried out in 21 pts (10 CPL, 11 OPNI), but was not done in 6 pts (3 CPL, 3 OPNI). A thoracic approach for DP was used in 12, an abdominal approach in 9 pts; re-plication for reappearance of diaphragmatic elevation after 2 thoracic and 1 abdominal DP was transthoracic. All 6 pts not plicated survived. Hospital death occurred in 9/21 (43%) DP pts (3/10 CPL and 6/11 OPNI), including 7 who could not be weaned from the ventilator. Late death occurred in 5/12 (42%) DP survivors (1 CPL and 4 OPNI). Thus, the mortality rate was 14/21 (67%) DP pts (4/10 CPL, 10/11 OPNI), and was 14/27 (52%) overall. None of the 8 pts without respiratory distress died, but 14/19 (74%) of those with respiratory distress died. No death was related to DP itself. The 7 long-term survivors of DP were extubated within 6 days after DP; those who died were intubated for 3 days to 1 year (2.8 ± 1.3 months, mean ± SEM). During the period of this study, 11 of 176 (6.3%) newborns ≤ 3 months old undergoing lateral thoracotomy for heart disease suffered OPNI, an unexpectedly high incidence. No OPNI occurred after 52 median sternotomies in newborns or after 707 sternotomies and thoracotomies in older children. We conclude that the mortality rate of infants with respiratory distress due to diaphragmatic malfunction is high; DP itself is safe and is equally effective from a thoracic or abdominal approach; intubation for longer than a week after DP is a very ominous prognostic sign; and the incidence of OPNI during lateral thoracotomy in newborns with congenital heart disease is greater than generally appreciated.

12:00 p.m. Adjourn for Lunch

*By Invitation