TUESDAY MORNING, APRIL 19, 1988

6:45 a.m. SIMULTANEOUS BREAKFAST SESSIONS**

(See page 5 for further information)

A) BLOOD CONSERVATION

Delos Cosgrove, III, M.D. Cleveland, Ohio

B) FLAPS - WHEN AND WHERE TO USE THEM

Peter C. Pairolero, M.D., Rochester, Minnesota

8:30 a.m. Scientific Session - Ballroom

16. Transhiatal Esophagectomy with Gastric Transposition for Pharyngolaryngeal Malignancies

MEL VYN GOLDBERG, JEREMY FREEMAN*,

G. ALEXANDER PATTERSON*, THOMAS R.J. TODD,

PATRICK J. GULLANE* and DONALD McSHANE*

Toronto, Ontario, Canada

Currently, in our center, laryngeal and early hypopharyngeal cancers are treated with radical radiotherapy (RT) with salvage surgery used for recurrent disease only. Late extensive disease is treated primarily with surgery and postoperative radiotherapy. We have found that gastric transposition with pharyngogastrostomy following pharyngolaryngectomy and transhiatal esophagectomy (PLE) provides an excellent functional result in these difficult management cases.

From 1981 to 1987, gastric transposition was used in 38 patients following PLE for hypoppharyngeal (22), laryngeal (11), cervical esophageal (4), and tracheal (1) carcinoma.

Indications for PLE included: salvage surgery (19), previous RT for other lesions (3) and late extensive disease (16). Thirty day mortality was one in-traoperative disseminated intravascular coagulopathy.

Of 31 patients evaluable, deglutition was excellent in 24, good in 3 and poor in 4. Minimum follow-up has been 3 months. Median survival time is 11 months. Fifty percent of patients survive one year and the 5 year actuarial survival is 33%.

The most frequent complications were fistula and flap necrosis, seen almost exclusively in patients receiving RT preoperatively (salvage surgery). There were 9 anastomotic leaks, 5 requiring further surgical treatment. Seven patients failed to leave hospital mainly because of fistula related complications.

Our experience indicates that gastric transposition functions well following pharyngolaryngectomy. There is a high postoperative fistula rate in those patients who have received previous high dose RT.

*By Invitation

**Admission will be by ticket only and will be limited. Tickets must be obtained in the Registration Area of the Century Plaza Hotel prior to 2:00 p.m. on Monday, April 18. There are no provisions for pre-registration. Breakfast will be served until 7:00 a.m. only.

17. Surgical Management of 100 Consecutive Esophageal Strictures

ROBERT D. HENDERSON, GARY MARRY ATT*

and ROBERTF. HENDERSON*

Toronto, Ontario, Canada

There is controversy as to whether esophageal peptic strictures requiring surgery should be treated by conservative repair or resection. In a group of 100 consecutive strictures, the aim was to preserve the esophagus using a total fundoplication gastroplasty (TFG). In this group 98 were treated by TFG and only two required resection. All were fully evaluated by history, radiology, manometry with pH, endoscopy and dilatation. Using TFG there was no mortality and 3% significant morbidity. The results in 98 patients varied depending on the severity of preoperative pathology. The major preoperative pathologic factors were a) severe stricture pathology; b) previous esophageal or gastric surgery and c) scleroderma. Severe stricture with extensive ulcera-tion was present in 35 patients, cleroderma in 13 patients and revision surgery in 26 patients. This cumulatively accounted for 54% of all patients. The results were tabulated as follows: A) asymptomatic; B) minor residual; C) major residual; D) failure.

	No.	A	B	C	D
Uncomplicated simple strictures	46	97.8	0	2.2	0
Complications 1 factor	35	91.4	5.7	2.9	0
2 factors	15	66.6	26.7	6.7	0
3 factors	2	0	0	50	50

Overall results in 98 patients showed 94.9% A and B, and 5.1% C and D. These results justify a conservative approach as there was no mortality, 3% morbidity and 94.9% acceptable results. Simultaneously by evaluating preoperative pathology there is also a method of preoperatively assessing and choosing to resect the most severe patients.

*By Invitation

18. Cervical Esophagogastric Anastomosis for Benign Disease - Functional Results

MARK B. ORRINGER and MACK C. STIRLING*

Ann Arbor, Michigan

Eighty-seven adult patients (average age 49 years) with various benign esophageal disorders treated by total thoracic esophagectomy and a cervical esophagogastric anastomosis have been followed with personal interviews and examinations from 1-104 months (average 34 months). Outpatient esophageal dilation has been used liberally for any degree of postoperative cervical dysphagia. At their latest follow-up, 34 patients (39%) eat without dysphagia; four patients (5%) have mild dysphagia requiring no treatment; 34 patients (39%) have undergone 1-3 dilations during the first 6-12 postoperative months for intermittent dysphagia; and 14 patients (16%) have more severe dysphagia requiring regular anastomotic dilations (two-thirds of these perform home self-dilations).

Mild regurgitation of gastric contents has been experienced by 26 patients (30%), particularly when recumbent after eating, but only three patients sleep with the head of the bed elevated to prevent nocturnal regurgitation. No patient has experienced pulmonary complications due to aspiration. Twenty patients (23%) have had varying degrees of "dumping syndrome", generally transient and well-controlled with medication. One patient has required a pyloroplasty for impaired gastric emptying 18 months after her initial esophagectomy and pyloromyotomy. At their latest evaluation, 37% of the patients weigh 3-83 (average 15) pounds more than they weighed preoperatively, 41% weigh 5-40 (average 12) pounds less, and 23% have had no change in their weight.

The stomach functions well as a visceral esophageal substitute, like the esophagus, is more thick-walled and resiliant than colon. Significant gastroesophageal reflux is uncommon after a properly performed cervical esophagogastric anastomosis. Problems of late redundancy seen with colon interpositions do not occur with the stomach. These data support our belief that the stomach is the preferred organ for esophageal replacement, not only for carcinoma, but also for benign diseases as well.

9:30 a.m. Intermission - Visit Exhibits

*By Invitation

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

19. Survival Analysis of Medical Versus Prompt Surgical Therapy in Patients with Triple Vessel Coronary Artery Disease and Severe Angina Pectoris: A Cass Registry Story

WILLIAM O. MYERS, HARTZELL V. SCHAFF*,

LLOYD D. FISHER*, BERNARD J. GERSH*,

MICHAEL B. MOCK*, DA VID R. HOLMES*,

THOMAS J. R YAN* and GEORGE C. KAISER

Seattle, Washington; Marshfield, Wisconsin; Rochester,

Minnesota; Boston, Massachusetts and St. Louis, Missouri

We compared survival differences during a six year follow-up of patients in the registry of the Coronary Artery Surgery Study (CASS) who had three vessel coronary artery disease and Canadian Cardiovascular Society Class III-IV angina pectoris. All had a 70% or greater stenosis in either the mid or proximal segment of all three coronary arteries. There were 679 medically treated patients (M) and 1921 surgically treated patients (S) in this nonran-domized comparison. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, the estimated probability of being alive at six years was 82% for S and 59% for M (p < .0001). This advantage of surgical treatment was observed in subgroups of patients with normal as well as ischemically damaged left ventricles (LV) and subgroups with zero to three proximal coronary artery stenoses.

For patients with normal LV, 90% of S and 78% of M were living at six years (p < .0001). For them, survival was significantly increased for S compared with M only if two or three proximal stenoses were present. For patients with no proximal stenosis and all categories of LV function, 84% of S and 67% of M were alive at six years (p < .0001).

Patients with the most severe LV dysfunction (LV score of 16-30) had a six year survival of 63% for S and 30% for M (p < .0001). Those with three proximal stenoses and all gradations of LV score had an 81% survival for S and 40% for M at six years (p < .0001).

In a multivariate (Cox) analysis of preoperative clinical, hemodynamic and angiographic factors, early surgery was the strongest predictor of survival.

*By Invitation

20. Carcinoma of the Lung: Evaluation of Satellite Nodules as a Factor Influencing Prognosis After Resection

JEAN DESLAURIERS, RAYMOND CARTIER*,

MARCIEN FOURNIER*, MAURICE BEAULIEU*

and MICHEL PIRAUX*

Quebec, Quebec, Canada

Like most solid tumors, lung cancer may be associated with satellite lesions. There is, however, no information available at the present time as to their definition, incidence, stage within the TNM terminology, management or prognosis following resection.

Over the past 18 years (1969-1987), we have identified 84 patients who had resection of a primary lung cancer associated with satellite nodules. There were 68 males and 16 females with a mean age of 58.3 years (37-76). All satellite nodules were clearly seen on the gross specimen, were separated from the main lesion by normal lung and were histologically identical to the primary carcinoma. In addition, they were all located within the same lung and usually within the same lobe (81%). Four subsets of nodules were identified: (a) Nodules peripheral to the main tumor (n:38), (b) Nodules around the main tumor (n:19), (c) Nodules in a different lobe (n:16) and (d) Nodules central to the main tumor (n:ll). Pre-operative Chest films were reviewed and in only 17% of patients could the satellite nodule be identified.

All patients underwent pulmonary resection (complete in 77/84, 92%) with 4 operative fatalities (4.6%). Forty-six patients had a pneumonectomy while the remaining 38 patients had lobectomies (n:35) or limited resections (n:3). The survival figures are summarized in the table and are compared to those of patients resected during the same time interval but who did not have satellite lesions.

	Stage	No. Pts.	Survival at 5 years(%)	Survival 10 years	p.
Stage 1	No Satell. nodules	566	54.4%	38.8%
	With Satell. nod.	40	9.5%	0.0%
					0.002
Stage 2,3	No Satell. nodules	459	36.8%	30.6%
	With Satell. nod.	44	21.4%	12.3%
					0.016
Total	No Satell. nodules	1,025	43.8%	30.1%
	With Satell. nod.	84	18.7%	10.8%
					0.001

These results indicate that the presence of satellite lesions has a negative impact on survival following surgery for lung cancer. These nodules should be carefully looked for by the pathologist and if they are found, the patient should probably be included in the M, subset of the TNM classification.

*By Invitation

21. Biochemical and Cytogenetic Studies of Human Lung Cancer

JOHN R. BENFIELD, STEVEN S. SMITH*,

YASUSHI OHNUKI*, JACK SHIVELEY*,

JOHN C. WAIN*, MARVIN DERRICK*,

WILLIAM G. HAMMOND* and HYUNK. PAK*

Los Angeles and Duarte, California

Work-up of lung cancers at the cellular level is a future approach toward assessment of prognosis and rational planning for new management strategies. In ongoing studies, we have tested resected lung cancers from 43 men and 35 women; 65 patients are free of disease, 13 died of cancer.

Methods or measurements employed were: total cellular DNA content by image analysis (n = 78); total genomic DNA methylation state, and banding patterns from probed Southern blots (n = 31); radio-immunoassay (RIA) for bombesin, gastrin, VIP, cholecystokinin (n = 13); cytogenetics (n = 26).

All lung cancers were hyperploid. Adenocarcinomas were generally hex-aploid, epidermoid carcinomas nearly septaploid; findings compatible with polyclonality of the cancers. There was general hypomethylation of DNA (p 0.001). DNA digests (restriction endonuclease HpaII, probed with DNA homologous to KPN) showed banding patterns that correlated with cell types. These patterns separated histologically indistinguishable primary aden-ocarcinomas (n=13) and metastatic adenocarcinomas (n = 3) from one another. Cancers studied with RIA were all negative for polypeptide hormones. There were 6 cancers which grew adequately in vitro to permit study of 45 detailed karyotypes (3-15/tumor). The chromosome modal numbers range from 57-87. The number of clearly abnormal marker chromosomes ranges fom 4-20; abnormality in chromosome #1 was prevalent.

Information obtained by molecular biologic and cytogenetic methods distinguishes between primary and metastatic adenocarcinomas, and promises to be a new basis for treatment planning.

11:15 a.m. Address by Honored Speaker - Ballroom

DO WE REALLY CORRECT CONGENITAL HEART DEFECTS?

Jaroslav F. Stark, M.D., London, England

12:00 noon Adjourn for Lunch - Visit Exhibits

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

†Admission will be 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 Century Plaza Hotel prior to 2:00 p.m. on Monday, April 18. Residents will be the guest of the Association.

*By Invitation