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