2:00 p.m. Scientific Session - Grand
Ballroom
9. The Diagnosis and Treatment of
Gastroesophageal Reflux in Infancy
JOHN A. ST. CYR*,
THEODORE R. THOMPSON*,
DANA E. JOHNSON*, T.
BRUCE FERRARA*
and JOHN E. FOKER
Minneapolis, Minnesota
Many questions remain about the treatment of
gastroesophageal (GE) reflux in infancy. Some degree of GE reflux is very
common in infants and tends to reverse with time, therefore, the indications
for early surgery are not well defined. Furthermore, the complication rate and
the ability of the fundoplication to grow remains to be determined. To answer
these questions, we reviewed the records of patients 6 mos of age or younger
who underwent a Nissen fundoplication with gastrostomy tube placement between
1979 and 1985.
There were 41
patients (22 males, 19 females) with birth weights 0.65 to 4.3 kg. Signs and
symptoms of GE reflux were more varied than in older children and often
relatively subtle. Respiratory problems were common including recurrent
aspiration with choking or chronic pneumonitis (61%) and apneic and bradycardic
spells (17%). Failure to gain weight was present in 20% and intractable
vomiting in 2.5%. As expected, in these patients, 56% also had congenital
anomalies which, in many cases, were important to the prognosis. The diagnosis
was conformed by barium swallow in all but one patient in whom gross reflux
during feedings was present. Initially, an attempt at positioning and thickened
frequent feedings were tried in all patients for 3-4 wks. In one patient, however,
the severity of the respiratory problems precluded trial beyond 12 days.
Although all patients showed significant degrees of GE reflux, recommendation
for surgery could only be based on the severity of symptoms.
Patients who
failed medical management underwent Nissen fundoplication with gastrostomy tube
placement. Operative age ranged from 2 wks to 6 mos and weight from 1.02 to
6.95 kg. The only surgical complication was one gastrostomy leak. Prematurity
or preexisting anomalies led to 24% late deaths between 2 wks and 23 mos
postoperatively. There was complete resolution of symptoms in all survivors
with followups of 4-67 months. All were on a normal diet for their age except
one child requiring gastrostomy feedings because of neurological dysfunction. We
conclude: (1) significant GE reflux in infancy most frequently produces
respiratory problems which can be life threatening, (2) Nissen fundoplication
can be a safe and effective procedure in infants 6 mos of age or younger, and
(3) fundoplication appears to have good growth potential and does not lead to
late feeding problems. Consequently, because of the severity of problems
associated with GE reflux, surgical correction can be recommended for infants
not responding to conservative therapy.
2:10 p.m. Discussion
*By Invitation
2:20 p.m.
10. Reoperative Achalasia Surgery
F. HENRY ELLIS, JR.,
ROBERT E. CROZIER*
and S. PETER GIBB*
Burlington,
Massachusetts
We believe esophagomyotomy to be the treatment of
choice for esophageal achalasia and, in a recent review (J. Thor & Cardiov
Surg), reported a 94% improvement rate in patients operated on primarily.
Because reoperations were attended by less good results, we have reviewed our
experience with reoperative achalasia surgery with emphasis on the indications
for reoperation and the results of the various operative procedures employed.
Since January
1970, forty-six achalasia patients whose original operation was performed
elsewhere in all but 6 have required reoperation for a variety of reasons
including gastroesophageal reflux (14), inadequate myotomy (10), concomitant
antireflux procedure (5), healed myotomy (5), incorrect diagnosis (4),
carcinoma (4), megaesophagus (3), and paraesophageal hiatus hernia (1).
Surgical management was individualized, a number of different operations being
used. The overall improvement rate in patients followed longer than 1 year was
85% with the more radical procedures particularly esophagogastrectomy,
antrectomy and Roux-Y-gastro-jejunostomy having the best symptomatic results when
compared to the results of more conservative procedures (100% excellent or good
results as compared to 55%).
These findings
emphasize the need for accurate diagnosis, early myotomy before the development
of megaesophagus, and attention to certain technical details of esophagomyotomy
if the need for reoperation is to be minimized. They also suggest that under
certain circumstances, a radical surgical procedure may be required in order
for reoperative achalasia surgery to be successful.
2:30 p.m. Discussion
*By Invitation
2:40 p.m.
11. Surgical Treatment of the Failed Anti-Reflux
Operation
MACK C. STIRLING*
and MARK B. ORRINGER
Ann Arbor, Michigan
In 11 years, 89 adult patients have been reoperated
upon for recurrent gastroesophageal reflux or complications of prior
anti-reflux procedures. 59 had a radiographic hiatal hernia (47 sliding and 12
paraesophageal), and 20 had distal esophageal obstruction (17 from reflux
esophagitis and 3 from other causes, including 2 Angelchik prostheses).
Operations performed included transthoracic Collis-Nissen procedure (58),
Collis-Belsey repair (14), Nissen fundoplication (1), repair of acute
postoperative paraesophagheal hernia (1), division of obstructing crural suture
(1), and esophageal resection (14).
Among the 72
patients undergoing an additional hiatal hernia repair, there were 2
postoperative deaths and 3 non-fatal esophageal leaks. Follow-up ranges from
1-118 months (average 28 months). Subjectively, results have been excellent or
good (no or mild reflux symptoms or dysphagia) in 46 (64%); fair in 14 (19%)
who have moderate dysphagia (8) or reflux symptoms controlled medically (6);
and poor in 12 (17%) who have required additional surgery for either recurrent
reflux or dysphagia. Early postoperative esophageal dilations have been
required in 24 patients (33%) and regular dilations in 10 patients (14%).
Objectively, pH probe reflux control has been unsatisfactory in 7 (10%).
Among the 14
patients undergoing esophageal resection, 2 had a distal esophagectomy and short
segment colon interposition, and 11 had a trans-hiatal esophagectomy without
thoracotomy, 8 with esophageal replacement using stomach and 3 using colon.
There were no operative deaths. With follow-up of 1-84 months (average 17
months), 8 have had esophageal dilations (6 early and 2 regularly), and none
has clinically significant reflux symptoms. The results of "redo hiatal hernia
surgery" are far from ideal. Optimal surgical treatment of the failed
anti-reflux operation requires a careful radiographic and endoscopic analysis
of the existing anatomy, knowledge whenever possible of the type of initial
procedure, and experience to decide when esophageal resection is a safer and
more reliable approach than another hiatal hernia repair.
2:50 p.m. Discussion
*By Invitation
3:00 p.m.
12. Intraoperative Coronary Angioscopy:
Technique and Results in the Initial Forty Patients
AURELIO CHAUX*,
MYLES E. LEE,
CARLOS BLANCHE*,
ROBERT M. KASS*,
TODD C. SHERMAN*,
ANN E. MICKEY*,
FRANK LITVACK*,
WARREN GRUNDEEST*,
JAMES S. FORRESTER*
and JACK M. MATLOEE
Los Angeles,
California
Coronary angioscopy provides images of
intravascular detail with greater than 0.2 mm spatial resolution and excellent
contrast resolution. Forty patients underwent intraoperative angioscopy of
coronary artery and/or saphenous vein coronary bypass grafts. Using endoscopes
of 1.5 and 1.8 mm O.D., 65 native coronaries and 28 vein grafts were examined.
A clear viewing field was created by infusion of crystaloid cardioplegia
through the aortic root on cardiopulmonary bypass. Technical details crucial
for obtaining high quality images were: 1) sufficient coronary perfusion by
cardioplegic solution to displace all blood; 2) adequate intraluminal
illumination; and 3) high quality fiberoptic and lens systems. Incomplete
studies in approximately 25 percent of patients were related to failure to
achieve these technical details, and by lack of scope steerability. In 30
percent of patients, previously unrecognized anatomic details were revealed by
angioscopy. These included intimal flaps at the site of vein-artery
anastomosis, atheromatous plaque with adherent thrombi (not recognized on
angiography), and hemorrhagic ulcerated plaques. Although one patient developed
a coronary intimal flap proximal to the anastomosis during retrograde
examination with an early model angioscope, no serious complications occurred
secondary to the procedure. We conclude that: 1) intraoperative angioscopy is
safe; 2) provides novel information which is clinically relevant; and 3) has
future potential for coronary endarterectomy, intraoperative balloon and laser
angioplasty.
3:05 p.m. Discussion
*By Invitation
3:10 p.m.
13. Comparison of Continuous Wave Lasers
for Endarterectomy of Experimental Atheromas
JOHN EUGENE*, MARC
E. POLLOCK*,
STEPHEN J.
McCOLGAN*, MARIE HAMMER-WILSON*,
MICHAEL W. BERNS*
and C. ROBERT MASON
Irvine, California
The standard
surgical lasers, argon ion, Nd-YAG, and carbon dioxide are all continuous wave
(CW) lasers with specific uses. We have previously demonstrated the superiority
of argon ion over Nd-YAG for laser endarterectomy. Recently carbon dioxide
endarterectomy has been proposed and clinical trials are underway with all 3
lasers. Therefore, we compared these 3 lasers under controlled experimental conditions.
A thoracoabdominal exploration was performed in 17 arteriosclerotic rabbits.
The aorta was isolated, heparin administered, and multiple endarterectomies
were performed in each rabbit with each of the lasers. A line of laser craters
was created at the proximal and distal ends of an atheroma. CW laser radiation
was used to connect the craters thereby forming proximal and distal end points.
The plaques were dissected free from the aorta with laser light and the end
points were fused by laser. The aortas were removed for light microscopy and
the animals were sacrificed. The endarterectomy surfaces and end points were
serially sectioned and graded according to light microscopic findings (1 =
worst, 4 = best). Argon ion laser endarterectomy (N = 16) required 106 ± 10
J/cm2. The surface score was 3.5 and end point score 3.4. Nd-YAG
laser endarterectomy (N=13) required 1289 ± 115 J/cm2 with a surface
score of 2.4 (p<.01 from argon ion) and an end point score of 1.3 (p<.005
from argon ion). Carbon dioxide laser endarterectomy (N = 9) required 30 ± 5
J/cm2 with a surface score of 2.0 (p<.01 from argon ion) and an
end point score of 1.6 (p<.005 from argon ion). Perforation occurred in 1/16argon ion studies (technical error, not laser), in 11/13 Nd-YAG studies and
in 6/9 carbon dioxide studies. This study demonstrates that of the currently
available clinical CW lasers, the argon ion laser remains superior for
endarterectomy of experimental atheromas.
3:15 p.m. Discussion
*By Invitation
3:20 p.m.
14. Constant Postoperative Cardiac Output
Monitoring Following Correction of Congenital Heart Defects
BLAIR A. KEAGY*,
BENSON R. WILCOX,
CAROL L. LUCAS*,
HENRY S. HSIAO*,
G. WILLIAM HENRY*,
MICHAEL BAUDINO*
and GENE BORNZIN*
Chapel Hill, North
Carolina and Minneapolis, Minnesota
A new method has been developed which permits
constant postoperative monitoring of mean and phasic cardiac output (CO) in
patients following correction of congenital heart defects (CHD). A miniature
ultrasound probe (USP) is attached to the adventitia of the ascending aorta at
the conclusion of the operative procedure and is connected to the monitoring
equipment by means of polyurethane covered wires which exit the chest wall
through a small stab wound. The probe can be easily removed by gentle traction
when the patient's condition is stable. The technique was developed, validated,
and refined in extensive animal studies, and this report describes the first
series of 20 consecutive human implants, performed between August 1984 and
September 1985, in which the absolute CO determination obtained with the USP at
the time of its application was correlated with CO as measured with a standard
electromagnetic flow probe (EMFP). There were 14 males and 6 females whose mean
age was 5.5 years. Operations performed included 8 atrial septal defect
repairs, 4 procedures for tetralogy of Fallot, 3 ventricular septal defect
repairs, 3 stenotic valve corrections and 2 Senning operations. There was one
operative mortality, but there were no complications related to probe
application or removal. The average CO in the 20 patients as measured with the
USP was 2.2 ± 1.1 L/min (range = .67 to 5.27 L/min), which is nearly identical
(p>.4) to the results noted using the EMFP, where the mean CO was 2.3 ± 1.2
L/min (range = .7 to 6 L/min). Regression analysis revealed a high linear
correlation (r = .9) between the two techniques. A monitor can display the CO
trend with one-minute updates, greatly enhancing management of intravenous drug
therapy and volume administration. In conclusion, this new extraluminal
removable probe allows postoperative CO monitoring following correction of CHD
and should become a standard technique in the postoperative care of these
patients.
3:25 p.m. Discussion
3:30 p.m. Intermission
- Visit Exhibits - Exhibit Hall
*By Invitation
4:15 p.m. Scientific
Session - Grand Ballroom
15. Myocardial
Protection in the Neonatal Heart: A Comparison of Topical Hypothermia,
Crystalloid and Blood Cardioplegic Solutions
ANTONIO F. CORNO*,
HILLEL LAKS,
DANIEL BETHENCOURT*,
SUNITA BHUTA*,
HAKOB DAVTYAN*,
WILLIAM M. FLYNN*,
and DAVIS C.
DRINKWATER *
Los Angeles,
California
Neonatal myocardial metabolism, structure and
function are different from that of the adult heart. The requirements for
myocardial protection may therefore also differ.
This study
evaluated the myocardial protection achieved during two hours of ischemic
arrest in 42 neonatal piglets (age 1-5 days). Topical cooling (TC) was used in
9 piglets (Group I), hyperosmolar (450 m Osm) low Ca++ (0.5m Osm/1) crystalloid
cardioplegia (LCaC) in 15 (Group II), St. Thomas Cardioplegia (St.T) in 6
(Group III), cold blood cardioplegia (CBC) with K+ (23m Osm/1), C.P.D. (Ca ++
level = 0.3m Osm/1) and THAM in 7 (Group IV), and cold blood cardioplegia with
K+ alone (23m Osm/1) in 5 (Group V).
Stroke work
(SW) at baseline and during recovery (30' and 60' after re-perfusion) was
measured in isolated working hearts perfused with blood from an adult support
pig and beating against fixed afterload (80 mmHg). Hemodynamic recovery (% of
the pre-ischemic SW) after 30' and 60' reperfusion was 82.9% (N.S.) and 86.7%
(N.S.) in Group I (TC), 35.7% (p<0.00002) and 43.7% (p<0.00002) in Group
II (LCaC), and 70.3% (p<0.05) and 78.7% (N.S.) in Group III (St.T), 67.4%
(p<0.05) and 60.6% (p<0.02) in Group IV (CBC, K+, C.P.D., THAM), 110.2%
(N.S.) and 98.6% (N.S.) in Group V (CBC, K+). Electron microscopy of left
ventricular biopsies was normal in Groups I and V, and correlated with the
degree of impairment in Groups II, III and IV, with contraction bands,
mitochondrial swelling, interstitial hemorrhage and edema.
Conclusions: a)
Topical cooling and potassium cold blood cardioplegia allow complete structural
and functional recovery after 2 hours of ischemia in isolated neonatal piglet
hearts; b) low calcium CBC and crystalloid cardioplegic solution fail to
provide adequate myocardial protection in the neonate, indicating an increased
dependence on calcium compared to the adult heart.
4:20 p.m. Discussion
*By Invitation
4:25 p.m.
16. Minitracheostomy: A New Delivery System for
Jet Ventilation
HUGOE R. MATTHEWS*,
BARRIE FISCHER*,
BRENDAN E. SMITH*
and ROLAND B. HOPKINSON*
Birmingham, England
Sponsored by: THOMAS
R. DEMEESTER
Omaha, Nebraska
Minitracheostomy
is a recent technique in which a 4.0 mm ID PVC cannula is inserted into the
trachea by cricothyroid puncture using a commercially available kit (Portex
U.K. Ltd.). This provides constant access to the trachea for the removal of
secretions by suction, while preserving the patient's ability to talk and
generate an expulsive cough. As an additional facility we have designed a
simple external Y' connector which permits the delivery of jet ventilation via
the minitracheostomy. This produces a percutaneous system that allows full
access for ventilation and suction, without the need for a cuffed endotracheal
tube or sedation. The system can be used long-term and patients are able to
eat, drink and talk while being ventilated.
Up to October
1985 17 patients aged 31-77 years have been ventilated for a variety of
respiratory problems, using the combination of a minitracheostomy and a Penlon
ventilator equipped with a Bromsgrove humidifier. The main indications for
treatment were the complications of chronic obstructive airways disease and
post-operative cardiorespiratory failure. Ventilation was performed for periods
ranging from 12 hours to 14 days and was satisfactory in all but one case, as
judged by blood gas analyses, chest radiography and the clinical progress. Four
patients died from irreversible respiratory disease, but the remainder were all
weaned satisfactorily to spontaneous respiration. No complications related to
the minitracheostomy or the jet ventilation were identified.
Initial experience with this method indicates that
it is technically satisfactory and may offer important advantages over
conventional methods of ventilation, particularly in weaning patients from IPPV
and in those who do not require total ventilatory support.
4:30 p.m. Discussion
*By Invitation
4:35 p.m.
17. Circular Tracheal Replacement with Costal
Cartilage
FRANZ ECKERSBERGER*,
ERICH MORITZ*
and ERNST WOLNER *
Vienna, Austria
Sponsored by: THOMAS
W. SHIELDS
Chicago, Illinois
Permanent incorporation of any foreign material for
tracheal replacement produces granulation tissue which reduces blood supply to
connective tissue supporting an epithelial surface. 12 tracheal replacements on
dogs were done using costal cartilage strips for a neotrachea. 5 cm of the
thoracic trachea were resected and a tubular silicone prosthesis composed of
medical-grade silicone copolymer was implanted. Sewing rings were made of
absorbable Polyglactin 0.5 cm from the end in order to telescope the prosthesis
into the proximal and distal airway. Anastomosis were sewed with interrupted
sutures of Polyglactin. That prosthesis was then covered with autografts of
costal cartilage strips. Fibrin glue was only used between the strips as a help
for stabilization and as a stimulate of vascularisation. This construction was
then covered with mediastinal tissue. Silicone tube remained in place for
stabilisation as a temporary stent of the neotrachea up to 6 months and was
then extracted tracheoscopically. Neotrachea was observed without stenosis or
tracheomalacia up to 8 weeks after the extraction of the silicone tube
including good health of the animal. Histopathologic findings pointed out
survival of cartilage and a thin layer of vascularised tissue inside the
cartilage strips. In the subepithelial layer there was a network of vessels up
to 180 y in diameter. 3 weeks after extraction of the tube was an end-on
ingrowth of the epithelium. 6 weeks after extraction of the tube the electron
microscopy showed a basal-membrane like structure. The hole inner surface of
the neotrachea was covered by a layer of ciliated epithelium. This new
technique in circular tracheal replacement requires no long term incorporation
of foreign material.
4:40 p.m. Discussion
*By Invitation
4:45 p.m.
18. Pleural-Peritoneal Shunting for Recalcitrant
Pleural Effusions
GEORGE E.
CIMOCHOWSKI*, KOSTAM FARDIN*,
LEE R. JOYNER*,
ANTTIMARAN*
and ROBERT SARAMA*
Monroe, Louisiana
Sponsored by: THOMAS
R. DeMEESTER
Omaha, Nebraska
From March 1, 1984 to November 1, 1985, six
patients underwent pleural-peritoneal shunting for either malignant or benign
effusions that were intractable to the usual therapy. Five patients had
malignancy related effusions. One had a benign pleural effusion, a complication
secondary to radiation therapy. Prior therapy consisted of multiple
thoracentesis, chest tubes, multiple instillation of high dose (2 grams)
tetracycline and in addition, in the benign case, high doses of Lasix exceeding
450 mg. daily. A modified double valve Denver peritoneal-venous shunt was
inserted under local anesthesia in each case, shunting the right or left
pleural space to the sub-hepatic space or pelvic area. No early complication
was recognized in the peri-operative period. Each shunt is working in the
patients that are alive or functioned up to the time of death in the two that
are deceased. Intra-operative pressure data simultaneously recorded from both
chest and abdomen indicated spontaneous flow would not occur without active
pumping. All pleural effusions, including the solitary bilateral one, were
alleviated by pumping the shunt 20 times four times a day. Two of the cancer
patients died at one and two months from unrelated events with their
symptomatic pleural effusions relieved. There are two long term survivors alive
at 20 and 10 months respectively, one malignant and one benign. Technicium 90
pump-a-grams confirmed patency in both. The long term follow up revealed no
errosions, shunt failures, infection or symptomatic pleural effusions.
In summary, six patients had pleural-peritoneal
shunting performed and were followed from one to 20 months with successful
relief of the effusion in each case. There were no short or long term
complications recognized to date.
4:50 p.m. Discussion
*By Invitation
