TUESDAY, April 7, 1987

6:45-8:30 a.m.

SIMULTANEOUS BREAKFAST SESSIONS**

(See Page 16)

A. CONTROVERSIES IN HEART VALVE SURGERY-Columbus Hall

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

B. ADJUVANT CHEMOTHERAPY FOR LUNG AND ESOPHAGEAL CANCER: EXPERIMENTAL VS. ESTABLISHED-Columbus Hall

Moderator: David B. Skinner, M.D., Chicago, Illinois

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

19. The Management of Penetrating Lung Injuries in Civilian Practice

PAUL D. ROBISON*, P. KENTHARMAN*,

J. KENT TRINKLE and FREDERICK L. GROVER

San Antonio, Texas

Recent reports of military thoracic injuries have advocated early thoracotomy and aggressive management of pulmonary injuries with resection, as opposed to the more conservative and traditional treatment with chest tube thoracostomy. The following retrospective study was performed to determine the incidence of thoracotomy and lung resection in civilian injuries, and to evaluate the effectiveness of treatment of these injuries.

Methods: The records of patients admitted from 1973 to 1985 with penetrating thoracic trauma were reviewed. 1168 patients suffered 384 gunshot (GSW) and 784 stab wounds (SW) to the thorax.

Results: 283 patients with GSW (74%) and 602 SW (77%) were treated with chest tubes alone. Patients without penetration of the chest wall and patients with mediastinal injuries without pulmonary injury were excluded. 68 patients (6% of the total) required operative repair of pulmonary hilar or parenchymal injury; 64 patients underwent thoracotomy (40 GSW, 24 SW), and 4 patients required repair of lung injury during median sternotomy for heart or great vessel injury (2 GSW, 2 SW). Procedures performed at operation for lung injury in 31 (18 GSW, 13 SW), pulmonary resection in 18 (9 GSW, 9 SW), and repair or attempted control of hilar vessels in 10 (9 GSW, 1 SW). Of patients requiring pulmonary resection, 9 required wedge or segmental resection (2 GSW, 7 SW), 6 required lobectomy (4 GSW, 2 SW), and 3 patients required pneumonectomy (all GSW). Indications for lung resection were bleeding in 14 patients, severe parenchyma! destruction in 4, hemoptysis in 3, and central location of injury in 2 (some had more than one indication). Mortality for all thoracic injuries was 2.3% (18 of 384 GSW, 10 of 784 SW), for those treated with chest tube alone 0.7% for pulmonary hilar-injuries - 30% (3 of 10), for pts. with pulmonary parenchymal injuries - 8.6% (5 of 58), and for patients requiring lung resection 28% (4 GSW, 1 SW of 18).

Conclusion: Most civilian lung injuries can be treated by tube thoracostomy alone. Although relatively few patients with primary pulmonary injury require thoracotomy, those that do are at significant risk and may require lung resection to control bleeding, hemoptysis, or to remove destroyed or devitalized lung tissue.

*By Invitation

**Admission will be ticket only and will be limited. Tickets must be obtained in the Registration Area of the Hyatt Regency Chicago prior to 2:00 p.m. on Monday, April 6. There are no provisions for pre-registration. Breakfast will be served until 7:00 a.m. only.

20. Management of Complicated Cardiothoracic Problems with Pedicled Omental Grafts

DOUGLAS J. MATHISEN*, HERMES C. GRILLO

GUS VLAHAKES* and WILLARD M. DAGGETT

Boston, Massachusetts

The pedicled amentum finds use in cardiothoracic surgery for management of complicated problems and prevention of serious complications. Its blood supply is excellent, and it provides vigorous fibroplasia. Based on the right gastro-epiplotic artery, it reaches anywhere in the thorax or neck. Its bulk helps to fill infected spaces.

Twenty-five patients have been treated with the pedicled omentum. In 11 patients the goal was preventative, to avoid bleeding, leakage, and infection or to provide a source of fibroplasia. In 7 patients with cervical exenteration the flap protected against innominate artery erosion and esophageal leakage, generally in an irradiated field. In 2 patients it permitted primary healing of heavily irradiated trachea following a reconstruction - formerly unlikely. It was also used to provide coverage of a chest wall prosthesis and to buttress an iatrogenic esophageal perforation.

In 14 the omentum was used to obtain healing in the presence of infection. Bronchopleural fistulas were successfully closed in 4 of 5 patients. Four post-cardiac surgical mediastinal infections were successfully treated after prior debridements failed. One chronic esophago-pleuro-cutaneous fistula, 1 infected thoracoabdominal aortic graft, 1 tracheo-innominate arterial fistula, and 1 aorto-empyema fistula were successfully managed. One patient with an esophago-tracheo-carotic fistula had omentum placed to cover the esophageal fistula and the carotid artery stumps.

This series demonstrates the efficacy of pedicled omental grafts in management of complex cardiac, vascular, esophageal, tracheal, bronchial, pleural and chest wall problems.

*By Invitation

21. "Maximum" Thymectomy for Myasthenia Gravis: Surgical Anatomy, Operative Technique and Results

ALFRED JARETZKI, III, AUDREYS. PENN*,

MARIANNE WOLFF*, DAVID S. YOUNGER*,

ROBERT S. LOVELACE*, MARCELO OLARTE*

and LEWIS P. ROWLAND*

New York, New York

Complete removal of the thymus is the goal of surgery in the treatment of myasthenia gravis (M.G.). We have performed surgical-anatomical studies in 50 consecutive resections which demonstrate as many as 10 distinct lobes and foci of thymic tissue anywhere in the cervical-mediastinal fat. Our transcervical-transsternal-pleural en-bloc resection ("maximum" thymectomy) comes closer to complete thymectomy than any other procedure described.

95 consecutive patients with generalized M.G. operated upon using this procedure between 1978 and 1985 were followed 12-89 months - Group A (N-72) non-thymomatous M.G.; Group B (N-8) non-thymomatous M.G. re-explored for severe, incapacitating weakness after earlier transcervical or transsternal submaximal operations; and Group C (N-15) M.G. with thymoma. 79% (57) of Group A are markedly improved; 46% (33) in remission (clinically normal, no medications), 33% (24) asymptomatic on minimal doses of of pyridostigmine (P); 8 asymptomatic on immunosuppression (IS); 4 improved; only 3 unchanged: none are worse. In Group B, residual thymus was found in all; none are in remission; on medication (P or IS) 5 are asymptomatic, 2 improved, 1 unchanged. In Group C, 2 are in remission, 1 asymptomatic on P, 8 asymptomatic on IS, 2 improved, and 2 failed to improve and died in crisis.

Response to thymectomy in non-thymomatous M.G. was maximum at 1-4 years and did not depend upon age, sex, severity of disease, thymic hyper-plasia, or acetylcholine receptor antibody liter. Reoperation is indicated in patients with persistent or recurrent severe symptoms after more limited thy-mectomies, even though the results are less good. Patients with thymoma may eventually do well; however, due to their severe unstable M.G., their response is usually delayed and the long-term results are less certain.

These results support the recommendation for thymectomy in the treatment of M.G. and indicate a clear superiority of the "maximum" thymectomy procedure.

9:30 a.m. Intermission - Visit Exhibits - Wacker Hall Complimentary coffee available

*By Invitation

10:15 a.m. Scientific Session - Grand Ballroom

22. Care of Infants with Esophageal Atresia, Tracheoesophageal Fistula and Associated Anomalies

THOMAS M. HOLDER, KEITH W. ASHCRAFT

RONALD J. SHARP* and RAYMOND A. AMOURY

Kansas City, Missouri

In 100 consecutive patients with esophageal atresia and/or tracheoesophageal fistula, associated conditions were responsible for the majority of the deaths, both during the initial hospitalization and during a follow-up period of up to 10 years. The greatest risks were posed by cardiac, respiratory and gastrointestinal anomalies.

Care of the associated anomalies may take precedence over the care of the esophageal atresia. Each patient must be evaluated and a plan for therapy formulated, depending upon the type and the urgency of the associated conditions. Repair of esophageal atresia and tracheoesophageal fistula can be postponed safety by gastrostomy, upper pouch suction and parenteral nutrition while the concomitant condition is treated.

Nineteen patients required operative intervention for treatment of associated anomalies during the initial hospitalization - 11 of 17 patients with gastrointestinal anomalies, 5 of 17 for congenital heart disease and 3 of 7 for respiratory anomalies.

During initial hospitalization there were 3 pre-repair deaths from associated anomalies, 3 post repair deaths related to esophageal atresia and tracheoesophageal fistula and 2 post repair deaths related to associated anomalies. Thus 92 percent of the patients left the hospital alive. Of the 8 late deaths, 1 was related to esophageal atresia and 7 to other conditions.

*By Invitation

23. Manometric and Radionuclide Assessment of Pharyngeal Emptying Before and After Cricopharyngeal Myotomy in Patients with Oculopharyngeal Muscular Dystrophy

RAYMOND TAILLEFER* and ANDRE C. DURANCEAU

Montreal, Quebec

Fifteen patients with OPMD underwent cricopharyngeal myotomy (CM) to palliate their dysphagia. The aim of this work was to assess the effectiveness of this operation using radionuclide pharyngeal emptying study (RPES) as a new quantitative method in addition to clinical, radiological and manometric evaluation. RPES was performed in supine position following ingestion of 15 cc of water labeled with 99mTc-sulfur colloid. Computerized data were acquired at 0.5 sec. intervals for a duration of 15 minutes and hypopharyngeal time-activity curve was generated. Four quantitative parameters were evaluated: the time for pharyngeal clearance of 25%, 50% and 75% of the ingested activity and the pharyngeal stasis at 15 minutes. The median values and statistical analysis with the non parametric Wilcoxon-ranks test are summarized in the following table:

Pharyngeal Clearance	Before CM	After CM	P Value
25%	1.2 sec	0.9 sec	p<0.04
50%	4.0 sec	2.0 sec	p<0.005
75%	15.0 sec	7.0 sec	p<0.02
stasis at 15 min	10.3%	6.0%	p<0.01

Both pharyngoesophageal and tracheobronchial symptoms were improved by CM. Manometric evaluation showed a decrease of the upper esophageal sphincter (UES) closing pressure from 41.5 mmHg before surgery to 22.5 mmHg after CM (p<0.001). The UES resting pressure was 31.0 mmHg before and 12.0 mmHg (p<0.0005) after surgery.

CM significantly improves both symptoms and pharyngeal emptying in patients with OPMD.

*By Invitation

24. Selective Therapeutic Approach to Cancer of Lower Esophagus and Cardia

TOM R. DEMEESTER, GIOVANNI ZANINOTTO*

and KARL-ERIK JOHANSSON*

Omaha, Nebraska

The role of radical surgery for carcinoma of the lower esophagus and cardia is still controversial. Fifty-two patients with cancer in this location were referred to the senior author from 1980 to 1986. Thirty-two were squamous cell, 13 adenocarcinomas, 7 adenocarcinomas associated to Barrett's Esophagus. In 19, the tumor was not resectable and treatment consisted of bypass operation, intubation, or non-operative therapy. All expired within one year. In 19 patients a palliative resection could be done: 5 blunt esophagectomies, 10 standard esophagectomies and 4, who had a previous resection, had a second resection. The operative mortality was 20% (1/5) for blunt esophagectomy and 21% (3/17) for standard resection. Actuarial survival was 31% at one year. Only one patient was alive after two years. Fourteen patients had noncircumferential lesions of 4 cm or less in length on endoscopy and/or no evidence of spread to mediastinal lymph nodes on CT scan. They were considered to be potentially curable and compared to others, had earlier diagnosis (p<0.01) from the onset of the dysphagia and in 6 occult disease was discovered during endoscopy for GER symptoms. All were <75 years old, had FEVI> 1,500 cc and a resting ejection fraction >40%. A radical operation consisting of en bloc total esophagectomy, mediastinal lym-phadenectomy and 85-90% gastric resection with abdominal lymphadenectomy was performed; the left colon was used to reestablish the gastrointestinal continuity. The mean number of lymph nodes removed was 40.5 + 15.1 (range 65-18). Absence of full wall penetration and/or four or less regional nodes involved were consistent with preoperative evaluation in 86% of the patients. Operative mortality of radical resection was 7% (1/14) and the survival rate was 83%, 73% and 44% at one, two, and five years. Karnofsky's score of those alive is >90. Patients with tumor less than 4 cm in length and not circumferential on endoscopy and/or no evidence of spread to mediastinal nodes on CT scan can be potentially cured by radical resection with good long term prognosis and quality of life.

11:15 a.m. Address by Honored Speaker

"NEW FRONTIERS - NEW BARRIERS"

Professor Jean-Paul Binet, Paris, France

12:00 p.m. Adjourn for Lunch

Luncheon Service available in Exhibit Area - Wacker Hall

12:15 p.m. Cardiothoracic Residents' Luncheon†

*By Invitation

†Admission will be by ticket only. There are no provisions for pre-registration. Physicians in cardiothoracic residency programs must obtain a ticket at the Information/Message Desk in the Registration Area of the Hyatt Regency Chicago prior to 2:00 p.m. on Monday, April 6. Residents will be the guest of the Association.