TUESDAY MORNING, April 29, 1986

6:45-8:30 a.m.

SIMULTANEOUS BREAKFAST SESSIONS**

A. PROLONGED CIRCULATORY SUPPORT

Rendezvous Ballroom (3rd floor)

Moderator: L. Henry Edmunds, Jr., Philadelphia, Pennsylvania

J. Donald Hill, San Francisco, California

Joseph N. Cunningham, New York, New York

D. Glenn Pennington, St. Louis, Missouri

B. TRAUMA - CARDIAC AND NON CARDIAC

Le Petit Trianon (3rd floor)

Moderator: Martin F. McKneally, Albany, New York

RUPTURED AORTA

Quentin R. Stiles, M.D., Los Angeles, California

RUPTURED TRACHIA AND ESOPHAGUS

David S. Mulder, Montreal, Quebec

RUPTURED DIAPHRAGM

Robert F. Wilson, Detroit, Michigan

C. PROBLEMS IN CARDIAC SURGERY Trianon Ballroom (3rd floor)

Moderator: Gerard A. Kaiser, Miami, Florida

THE MANAGEMENT OF A PATIENT WITH ENDOCARDITIS AND ASSOCIATED PROBLEMS

D. J. Magilligan, M.D., Detroit, Michigan

MITRAL VALVE REPLACEMENT IN THE PRESENCE OF EXTENSIVE CALCIFICATION, LEFT ATRIAL CLOT, OR THE SMALL LEFT VENTRICLE

Lawrence H. Cohn, M.D., Boston, Massachusetts

TECHNICAL CONSIDERATIONS IN REOPERATIONS OF PATIENTS WITH CORONARY ARTERY DISEASE

Noel L. Mills, New Orleans, Louisiana

D. PROBLEMS IN GENERAL THORACIC SURGERY

Mercury Ballroom (3rd floor)

Moderator: John R. Benfield, Duarte, California

THORACIC SURGERY IN IMMUNOCOMPROMISED HOSTS

Lawrence Kaiser*, New York, New York

N₂LUNG CANCER

L. Penfield Faber, Chicago, Illinois

MEDIASTINAL TUMORS

John R. Benfield, Duarte, California

E. ESOPHAGEAL MOTOR DISORDERS Mercury Rotunda (3rd floor)

Moderator: W. Spencer Payne, Rochester, Minnesota

ACHALASIA

F. Henry Ellis, Jr., Boston, Massachusetts

DIFFUSE SPASM

Robert D. Henderson, Toronto, Ontario, Canada

SCLERODERMA

Mark B. Orringer, Ann Arbor, Michigan

**Admission will be by ticket only and will be limited. Tickets must be obtained in the Registration Area on the Second Floor of the New York Hilton prior to 2:00 p.m. on Monday, April 28. There are no provisions for pre-registration. Breakfast will be served until 7:00 a.m. only.

*By Invitation

8:30 a.m. SCIENTIFIC SESSION - Grand Ballroom

19. Long-Term Clinical and Functional Results of Sleeve Lobectomy for Primary Lung Cancer

JEAN DESLAURIERS, PAUL GAULIN*,

MICHAL PIRAUX*, MAURICE BEAULIEU*,

YVON CORMIER* and RAYMOND BERNIER

Ste-Foy, Quebec

Sleeve lobectomy is a lung saving operation where a portion of main bronchus is removed in order to preserve distal parenchyma. Current controversies relate to its safety, its adequacy as cancer operation as well as long-term function of the reimplanted lobe.

Between 1975-1985, sleeve lobectomy was done in 72 patients with lung cancer (RT upper lobe: 50, LT upper lobe: 17, RT upper and RT mid. lobes: 4, LT lower lobe: 1). There were no operative deaths but major complications occurred in 8% of patients. Most resected cancers were squamous (65/72) with complete resection in all but 4 patients.

Minimum 1 year follow-up was available in all patients (avg.: 50 months) and cumulative survival was correlated with nodal status. Five years survival rate for patients with N0 status (N:34) was 67% and for patients with N1 status (N:34) was 60%. There was no difference on survival (P<0.05) between patients with surgical or pathological N1 disease.

Overall (table) and regional lung function were studied in all patients (N:19) alive 4 or more years after surgery (avg. interval surgery/study: 6 years).

For the 12 patients studied preoperatively, there was no significant changes between pre and postoperative values. Differential function was determined by decubitus lateral test and ventilation/perfusion isotope scanning methods. In 15 patients with right lung bronchoplasty, avg. perfusion ratios were

41.1%	(RT lung)		and ventilation ratios were			48.3%	(RT)	In 4 patients
58.9%	(LT lung)					51.7%	(LT)
with left lung bronchoplasty, these ratios were						71%	(RT)	for perfusion and
						29%	(LT)
perfusion and		60%		(RT)	for ventilation. In all cases, V and Q was homogeneous
		40%		(LT)

throughout the reanastomosed lobes without gas trapping. From this study, the following conclusions can be drawn: (1) Sleeve lobectomy is a safe procedure which does not compromise long-term tumor free survival; (2) The presence of metastatic hilar nodes (N1) does not contraindicate the operation when complete resection is possible and (3) The remaining ipsilateral lobe(s) have a normal physiology and contribute significantly to overall pulmonary function.

8:40 a.m. Discussion

*By Invitation

8:50 a.m.

20. Endobronchial Carcinogenesis in Dogs

JOHN R. BENFIELD, WILLIAM G. HAMMOND*,

RAO R. PALADUCU*, HYUN Y. PAK*.

NORIO AZUMI* and RAYMOND L. TEPLITZ*

Duarte, California

Further progress against lung cancer requires clinical/basic-science studies of preneoplasia and early cancers. To make this more readily possible than with studies limited to humans, a canine squamous cell lung cancer model has been developed.

We have studied 110 dogs exposed by 11 focal endobronchial regimens to chemical carcinogens benzo(a)pyrene (BP), nitrosomethylurea (NMU), methylcholanthrene (MCA), and dimethylbenzanthracene (DMBA). A combination of NMU and BP caused the first invasive cancer in 1/7 (14%) dogs after 5.5 years. Unacceptable toxicity resulted from 3 of the 11 regimens used, i.e., NMU, DMBA, and adjuvant immunosuppression. Cancers were not induced by 4 regimens. The remaining 4 regimens in 58 dogs caused 9 T₀ cancers, 7 T_1-2N₀M₀ cancers, and 15 metastasizing carcinomas. The most recent regimen (30mg MCA q2-3 wks) produced 8/10 (80%) cancers at pre-selected sites within 2 years of first exposure.

The time course of a predictable, reproducible, neoplastic continuum which begins with epithelial hyperplasia and culminates with metastasis has been mapped. Squamous metaplasia occurs in 6-18 weeks; it is followed by progressive squamous atypia. The interval until invasive cancer develops (about 20 months with MCA) provides unique opportunity to sample repetitively from the preneoplastic bronchial mucosa. Serial cytologic specimens, studied by image analysis, have revealed progressive and significant (p<0.01) increase in mean total cellular DNA content from diploid in normal cells to greater than tetraploid in cancer cells. We have recently been successful with serial passage of 2 canine lung cancers into the fifth transplant generation in nude mice.

There is now a large animal model of squamous cell lung carcinoma which closely resembles lung cancer. The reproducible preneoplastic events occur over a time span short enough to be fiscally defensible, but long enough to permit biologic dissection and evaluation of clinically relevant diagnostic-therapeutic methods during the development of cancers at predictable, pre-selected sites.

9:00 a.m. Discussion

*By Invitation

9:10 a.m.

21. Thoracic Surgical Spectrum of Acquired Immune Deficiency Syndrome

JOSEPH I. MILLER and CHARLES R. HATCHER, JR.

Atlanta, Georgia

The Autoimmune Deficiency Syndrome (AIDS) has presented a complex and, as yet, unsolvable spectrum of pulmonary disease characterized by bizarre infections, pneumothoraces, respiratory distress and death. From January, 1982 to July, 1985 (42 months) a total of 38 patients (pts) were referred to the Cardio-Thoracic Surgical Service for a surgical procedure (excluding bronchoscopy). The diagnosis of AIDS was made by lifestyle, homosexual exposure, confirmed pulmonary pathology, and by laboratory confirmation of AIDS serology in the past four months. Surgical procedures consisted of closed chest thoracostomy - 14; tracheostomy - 6; open lung biopsy - 12; surgical closure of air leak and pleuordesis - 5; esophagogastrectomy -1. An additional 109 patients underwent fiberoptic bronchoscopy with transbronchial biopsy for AIDS. Thirty day hospital mortality was 10 of 38 patients. Six months mortality was 17 of 38 patients. Pulmonary pathology consisted of pneumocystis carinii (PC) - 7 pts; PC and cytomegalia-inclusion virus (CMV) - 3 pts; Kaposi's sarcoma - 2 pts; toxoplasmosis - 2 pts; idiopathic - 2 pts. Protective surgical measures consisted of double gloving, disposable linen, gas sterilization of instruments; disposable anesthetic tubing. Thoracic surgical involvement will play a dominant role in the management of AIDS patients until a method of treatment is found.

9:20 a.m. Discussion

*By Invitation

9:30 a.m.

22. Pulmonary Aspergillosis: Results of Surgical Treatment

RICHARD C. DALY*, JEFFREY M. PIEHLER*,

PETER C. PAIROLERO, VICTOR F. TRASTEK*,

W. SPENCER PAYNE and PHILIP E. BERNATZ

Rochester, Minnesota

Between 1953 and 1984, 68 patients (50 males and 18 females) underwent thoracotomy for pulmonary aspergillosis (PA). Aspergillus species was present in all patients; A. fumigatus was present in 56 (82%). Forty-eight patients (71%) had aspergillomas. None had allergic PA. Average age was 51.4 years (range 2 to 86 years). Predisposing factors were present in 64 patients (94%). Indication for operation was an indeterminate mass in 36, hemoptysis in 15, severe cough in 8, bronchopleural fistula in 4, obstructed bronchus in 2, and empyema in 3. Lobectomy was performed in 26, wedge resection in 22, pneumonectomy in 8, and segmentectomy in 6. Eight had open drainage. Resection was thought complete in 59 patients (87%). Intraoperative hemorrhage occurred in 1 patient. There were no intraoperative deaths. Hospitalization average 18.1 days (range 1 to 118 days). Complications occurred in 35 patients (51%), and included respiratory insufficiency in 13, prolonged air leak in 10, empyema in 10, bronchopleural fistula in 7, hemorrhage in 7, wound infection in 5, and residual pleural space in 5. Antifungal therapy was administered postoperatively in 22 patients. Thirty-day mortality was 22% (15 patients) and varied with type of resection (incomplete, 55%) and form of disease (aspergilloma 19%). Cause of death was sepsis in 7, pulmonary in 5, and cardiac in 3. Follow-up averaged 38.6 months (range 1 month to 19 years). Ten of the 53 operative survivors (19%), had persistent documented symptomatic PA. There were 17 late deaths, 4 (24%) secondary to PA. We conclude that PA requiring surgical intervention remains life-threatening. Risks of operation are high and the possibility of long-term cure remote.

9:40 a.m. Discussion

*By Invitation

9:50 a.m.

23. Resection of Thoracic and/or Abdominal Teratoma in Patients Following Cisplantin-Based Chemotherapy for Germ Cell Tumor - Late Results

PATRICK J. LOEHRER*,

ISIDORE MANDELBAUM, SIU HUI*,

STEVEN CLARK*, LAWRENCE E. EINHORN*,

STEPHEN D. WILLIAMS* and JOHN P. DONAHUE*

Indianapolis, Indiana

Fifty-one patients with primary testicular (N = 46) or mediastinal germ cell cancer (N = 5) were treated from April, 1975 through May, 1981 and had teratoma resected from residual disease following cisplatin-based combination chemotherapy. All patients had normal serum markers prior to resection of pulmonary (12), mediastinal (5), thoracoabdominal (8), supraclavicular (1), or abdominal disease (25). Teratoma was classified as mature teratoma (MT) (N = 29), immature teratoma (IT) (N = 15), or IT with nongerm cell elements (IT_S) N = 7). Thirty-one of 51 (61%) patients remain free of recurrent disease while 20 patients either developed recurrent carcinoma (RC) N= 10) or teratoma (RT) N= 10). In the RC group, after additional chemotherapy, three are alive and disease-free; two are being treated with disease, and five died. In the RT group, after additional surgery, eight of ten are long-term survivors.

Four patients developed their initial relapse of carcinoma beyond two years. Univariate factors predicting for relapse include tumor burden, IT_S, and site (mediastinum), while only ITs and site predicted for survival. Immature teratoma and MT had similar relapse free intervals and overall survival.

Using a multivariate analysis, primary tumor site at the mediastinum is the most significant adverse factor predictive for both relapse and survival (two of five patients survived). This study appears to support the various preclinical models which demonstrate multipotential capabilities of teratoma. Complete surgical excision of teratoma remains the most effective treatment with continued close follow-up recommended for high risk patients (IT_S, large tumor burden, or primary mediastinal tumors).

10:00 a.m. Discussion

10:10 a.m. Intermission - Visit Exhibits - Exhibit Hall

*By Invitation

10:50 a.m. Scientific Session - Grand Ballroom

24. Surgical Technique for Successful Human Lung Transplant

JOEL D. COOPER, F. GRIFFITH PEARSON,

GEORGE A. PATTERSON*, THOMAS R.J. TODD*,

ROBERT J. GINSBERG, MELVYN GOLDBERG

and WILFRED DEMAJO*

Toronto, Ontario

We have reported two successful cases of unilateral lung transplant for chronic end-stage lung disease. A 58 year old male received a right lung transplant two years ago, and a 35 year old female received a left lung transplant one year ago. Both were discharged from hospital six weeks following operation and subsequently have led normal lives. Donor and recipient operations were performed in adjacent operating rooms. Unilateral lung anesthesia was utilized for both recipients. The groin vessels were prepared for cardio-pulmonary bypass though bypass was not required for either case. Extraction of the recipient's diseased lung was carried out without the need for anticoagulation, and total blood loss averaged 1 unit. The donor heart-lung block was removed and the donor lung then excised. The pulmonary artery was taken with a cuff of adjacent main pulmonary artery to allow for any discrepancy between a large recipient vessel and a normal sized donor artery. The bronchus was divided at the level of the trachea and subsequently trimmed back if necessary. A large cuff of donor pericardium was left attached to the hilum of the donor lung and used for reinforcing suture lines and as a route for development of collateral systemic blood supply. The donor harvesting technique does not preclude use of the heart for transplantation. The donor lung was not flushed, but was cooled by immersion in a basin of cold crystalloid. An atrial cuff was used for the venous anastomosis. Bronchial anastomosis was done in end-to-end fashion and was wrapped with an omental pedicle raised from the abdomen, based upon our laboratory findings that such a technique protects the anastomosis and rapidly restores systemic bronchial blood supply. Prior to performing bronchial anastomosis, the vascular clamps were removed to allow inspection of the suture lines for bleeding. To prevent hypoxemia during this phase, the donor lung was inflated through the open donor bronchus either by means of a jet ventilator or by intubation across the field. Total donor lung ischemic time was less than 90 minutes.

Success in these cases is attributed to careful patient selection, use of cyclosporine, and use of a pedicle omentum to protect and improve healing of the bronchial anastomosis.

11:00 a.m. Discussion

*By Invitation

11:10 a.m.

25. Autoperfusion of the Heart and Lungs for Preservation During Distant Procurement

ROBERT L. HARDESTY and BARTLEY P. GRIFFITH

Pittsburgh, Pennsylvania

Donation has been a major problem with 29 heart-lung transplants performed between May 1982 and October 1985. Inability to statically preserve lungs for more than 1½hours initially made it necessary to remove heart and lungs in a room adjacent to the recipient. Recently, 12 distant donors have been used with 4½ to 6 hours of extracorporeal auto-perfusion of the heart and lungs.

Autoperfusion of the heart and lungs was at 37 °C with donor whole blood, without additives. Mean arterial pressure was determined by the height of the reservoir. Cardiac output and pulmonary flow were regulated by controlling venous return. Banked blood was given to the donor when the reservoir was filled and resulted in a compensated metabolic acidosis at the outset. Ventilation with 90% room air and 10% CO₂ maintained or improved pH and gas exchange. Sterile wrapping for transportation is shown.

Cardiac and pulmonary function was initially satisfactory in 12 recipients. Medians of a single determination which was representative of the blood gases during the first 12 hours of implantation in all 12 recipients are:

pO2	FiO2	PEEP	pCO2	pH	Rate	TV
152	0.6	6.2	41	7.43	20	900

In 2 recipients, pulmonary function was initially satisfactory but later deteriorated without an explanation other than the possibility of inadequate preservation.

11:20 a.m. Discussion

11:30 a.m. Address by Honored Speaker

"The Cardiovascular Surgeon and the Liver"

Professor Ake Senning, Zurich, Switzerland

12:15 p.m. Cardiothoracic Residents' Luncheon -Petite Trianon Ballroom

*By Invitation