MONDAY AFTERNOON, May 6, 1991

1:30 p.m. SCIENTIFIC SESSION - International Ballroom

6. Barrett's Ulcer: A Surgical Disease?

WARREN A. WILLIAMSON*, F. HENRY ELLIS, JR.,

PETER S. GIBB* and H. THOMAS ARETZ*

Burlington, Massachusetts

Published reports on the treatment of Barrett's ulcer are controversial and sparse. Our experience with the management of this disorder over the past 16 years suggests that surgical therapy is rarely indicated.

Two hundred eighty-five cases of Barrett's esophagus were treated from 1974 to 1990. Seventy-three of these patients either presented with adenocarcinoma in Barrett's or developed it while under surveillance. Of the remaining 212 patients with benign Barrett's esophagus, 30 were found to have Barrett's ulcer on endoscopy, for a prevalence of 14%. Ulcers varied in size from 0.5cm to 3cm, sixteen (53%) being 1 cm or larger. Heartburn (70%), dysphagia (60%), and bleeding or anemia (23%) were the most common presenting symptoms. No patient exhibited either free perforation or perforation into the mediastinal structures. Ten patients (30%) admitted to heavy alcohol consumption.

Initial treatment consisted of aggressive medical therapy including H₂ antagonists and antacids as well as the usual dietary and anti-reflux measures. Three patients were lost to follow-up and twenty-seven were initially re-endoscoped in 2-4 months. Total endoscopic follow-up was 109 patient-years with a range of 2 months to 13 years and a median of 2.3 years. Complete healing occurred in 23 of 27 patients (85%) in two to 14 months (median 4 months). Seven of the 23 (30%) developed recurrent ulceration which healed in five with further medical therapy. A Nissen fundoplication or a Collis-Nissen was performed in four of the six patients with non-healing Barrett's ulcers, 1 to 1.5 cm in size, and they subsequently healed. Two patients refused surgery.

We conclude that the majority of Barrett's ulcers will heal on medical therapy, even large ulcers (2-3cm) and recurrent ulcers. We reserve surgical intervention for otherwise suitable operative candidates if there is no evidence of healing of the ulcer after a minimum of four months of medical therapy and prefer the Nissen fundoplication or one of its modifications. Perforation, uncontrollable hemorrhage, and malignant degeneration, not encountered in this series, are of course, indications for urgent surgical intervention.

*By Invitation

7. Primary Repair of a Wide Spectrum of Esophageal Atresia

EDWARD M. BOYLE, JR*, ERICD. IRWIN*

and JOHN E. FOKER

Minneapolis, Minnesota

Surgical repair of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) in infants with a wide gap length has continued to be a difficult problem. This study demonstrates, however, that primary repair can be safely carried out in infants with a wide spectrum of esophageal gap lengths. From 1976 to 1989, 56 infants with EA, with (54) or without (2) associated TEF(s), underwent primary repair. A very wide gap length (≥ 2.5 cm) existed in 15/56 (27%). Three infants had gap lengths of 4-7 thoracic vertebrae, two with pure EA and one with a proximal TEF with a short blind distal segment. These three infants underwent gastrostomy placement but after six weeks had no significant decrease in gap length. The wide gap in five other infants was related to an associated vascular ring. Since 1983 no infant was staged for interposition, even with an ultrawide gap. All 56 patients had a primary anastomosis without lengthening procedures such as circular myotomy. Our results include no deaths related to the operation (0%), nor apparent leaks (0%) nor recurrent TEF's (0%). Eight (14%)late deaths occurred (16-300 days postop) secondary to prematurity or other anomalies, thus demonstrating that survival depends on the severity of associated problems. One infant required a second operation for an unsuspected cervical TEF. Significant gastroesophageal reflux (GER) was found in 32/56 (57%) and was most common in the wide gap group. Fun-doplication was required in 13/56 (23%) and severe tracheomalacia was treated by aortopexy in 5/56 (9%) infants. All patients underwent two prophylactic dilations with 19/56 (34%) requiring additional dilations of anastomotic narrowing. One patient (2%) required late resection of an anastomotic stricture. All 48 surviving patients are now eating a diet normal for age (follow-up 0.75-16 years). In summary: (1) Primary repair can be reliably performed for the full spectrum of EA defects. (2) With our technique, a gap which exceeds 2.5 cm does not preclude successful primary repair despite the resulting great anastomotic tension. (3) With wide gap EA later operations for GER and the need for additional dilations are more common. (4) We conclude that infants born with EA can expect an adequately functioning native esophagus after this type of repair.

*By Invitation

8. Surgery for Subclavian Vein Effort Thrombosis

J. ERNESTO MOLINA

Minneapolis, Minnesota

Effort subclavian vein thrombosis (ESCVTO) occurs suddenly in young active people without premonitory signs or symptoms. If not treated as an emergency, permanent disability is common. Our protocol entails direct lysis of the clot via a catheter in the subclavian vein (Urokinase at the dose of 3,000 u/kg/wt) for 12-24 hours followed by surgery. The operation is done via a subclavicular approach for 1st rib resection and subclavian vein patch angioplasty is done if necessary. Residual stricture is treated with in-traluminal balloon angioplasty. Out of 27 patients seen, 23 were treated with this regimen. 16 on the right and 7 on the left. Three groups were identified: a) acute, < 5 days (6 pts.). Tears in the veins but no strictures were present, b) sub-acute, > 6 days (7 pts.), stricture present in 4 patients, c) chronic, > 2 weeks (10 pts.) comprising two categories: 1) short segment of subtotal obstruction (6 pts.), and 2) long segment of total obstruction (4 pts.). Vein patency with normal or near normal caliber and flow was achieved in all of groups a and b, and 7 patients in group c (87%). ESCVT must be treated as emergency for successful re-establishment of normal vein patency. The subclavicular approach to the first rib is simple direct and offers no risk of damaging vital structures. This method is less cumbersome than the transaxillary or posterior approaches and relieves any type of vascular thoracic outlet obstruction.

2:30 p.m. BASIC SCIENCE LECTURE

Transplant Immunology: A Broadening of the Concept for the Future

Fritz H. Bach, M.D., Ph.D., Minneapolis, Minnesota

3:15 p.m. INTERMISSION - VISIT EXHIBITS

*By Invitation

4:00 p.m. SCIENTIFIC SESSION - International Ballroom

9. Transesophageal Echocardiography in the Emergency Surgical Management of Patients with Aortic Dissection

PAUL SIMON*, ALYSONNINA OWEN*,

MICHAEL HA VEL*, ERNST WOLNER,

MICHAEL HIESMAYR* and WERNER MOHL*

Vienna, Austria

To investigate the benefit of transesophageal echocardiography (TEE) in the diagnosis of aortic Type A dissection, 15 consecutive patients were studied.

Patients were evaluated immediately upon admission. The intimal flap was visualized in all 15 patients. The primary entry site was correctly identified in 14 patients (93%). The entry site which was misdiagnosed by TEE was also misdiagnosed by angiography and NMR. Significant aortic regurgitation was encountered in 2 patients and mild insufficiency in 3. Involvement of the coronary arteries was ruled out in all patients. Pericardial tamponade necessitating immediate surgery was detected in one case. Five patients of this series underwent surgery based on TEE alone. Intraoperative TEE monitoring was used to verify retrograde flow in the true lumen after femoral can-nulation. The surgical result was evaluated immediately after termination of cardio-pulmonary bypass. TEE documented no flow in the false lumen in 13 patients. In two patients small intimal tears were detected in the descending thoracic aorta. Aortic regurgitation had resolved in all patients.

We conclude that TEE allows expedient diagnosis of type A aortic dissections and recommend TEE as the primary bedside diagnostic modality. It can especially be used to identify patients requiring surgical intervention without further delay due to other diagnostic procedures.

*By Invitation

10. Atheroembolism from the Ascending Aorta: An Emerging Problem in Cardiac Surgery

CHRISTOPHER I. BLAUTH*, BRIAN WEBB*,

NORMAN B. RATLIFF*, BRUCE W. LYTLE,

FLOYD D. LOOP and DELOS M. COSGROVE

Cleveland, Ohio

As patients undergoing cardiac surgery increase in age, noncardiac causes of death have increased. To identify these causes, autopsy findings in 221 patients undergoing myocardial revascularization or valve surgery, between 1982 and 1989, were analyzed. Mean age was 65.6 ± 9.5 and ranged from 32 to 94 years; 130 (58.7%) were males. Autopsies were complete in 129 patients (58.4%) and limited to the chest and abdomen in the remainder.

Embolic pathology was identified in 69 patients (31.2%). Atheroemboli or pathology consistent with atheroemboli were identified in 48 (21.7%). Fourteen had thromboembolism; 7 had disseminated intravascular coagulation. The incidence of atheroembolic pathology increased dramatically from 4.5% in 1982 to 48.2% in 1989 (p<0.0001). Atheroembolic pathology was found in the brain in 16.3%, spleen in 10.9%, kidney in 10.4%, and pancreas in 6.8%. Thirty (62.5%) of the patients had multiple atheroembolic sites. Atheroemboli were more common in patients undergoing coronary artery procedures (43/165; 26.1%) than in those undergoing valve procedures (5/56; 8.9%) (p = 0.008).

There was a high correlation of atheroemboli with severe ascending aortic atherosclerosis. Atheroembolic events occurred in 46 of 123 patients (37.4%) with severe disease of the ascending aorta but only 2 in 98 patients (2%) without significant ascending aortic disease (p<0.0001). Forty-six of 48 patients (95.8%) who had evidence of atheroemboli had severe atherosclerosis of the ascending aorta.

There was a direct correlation between age, severe atherosclerosis of the ascending aorta, and atheroemboli.

Patient age	<60	61-70	≥70	p Value
	N = 46	N = 96	N = 79
Aortic atherosclerosis	26.1%	61.5%	65.8%	<0.001
Atheroemboli	10.9%	20.8%	29.1%	0.05

We conclude that atheroembolism to the brain and other organs is emerging as a major problem in cardiac surgery, particularly in patients having coronary operations. The incidence correlates directly with age and severe atherosclerosis of the ascending aorta.

*By Invitation

11. Management of the Severely Atherosclerotic Aorta During Cardiac Operations: A Strategy for Detection and Treatment

THOMAS H. WAREING*, VICTOR G. DAVILA-ROMAN*,

BENICO BARZILAI", SUZAN F. MURPHY*

and NICHOLAS T. KOUCHOUKOS

St. Louis, Missouri

Embolization of atheroma from manipulation of the ascending aorta is one of the principal causes of stroke following cardiac surgical procedures. We have previously shown that intraoperative ultrasonographic scanning of the aorta using a high frequency (7.0 MHz) linear ultrasound transducer with longitudinal and transverse views rapidly, safely, and accurately identifies severe atheromatous disease in the ascending aorta and is far more effective for diagnosis than palpation of the aorta. Intraoperative ultrasonography of the ascending aorta was performed in 331 of a consecutive series of 362 patients (pts) 50 years of age or older (mean 69 years) who underwent a variety of cardiac surgical procedures. Forty-eight patients (14.5%) with a mean age of 72 years (range 55-85 years) were identified as having significant atheromatous disease in the ascending aorta at the usual sites for cannulation or clamping or diffusely throughout the ascending aorta, and were considered to be at increased risk for embolization. Palpation identified the disease in only 23 (48%) of these patients. A total of 107 modifications in the standard techniques for cannulation and clamping of the aorta were implemented. These included alterations in the sites of aortic cannulation (35 pts), aortic clamping (34 pts), attachment of the vein grafts (23 pts), and cannulation for infusion of cardioplegia (15 pts). Additionally, 8 patients with severe diffuse atheromatous disease underwent graft replacement of the ascending aorta using hypothermic circulatory arrest without aortic clamping, and one patient underwent coronary artery bypass grafting with femoral artery cannulation, hypothrmic fibrillatory arrest and internal mammary artery grafts. Thirty day mortality for the entire group was 2.4% (8 pts). Permanent neurological deficits occurred in 5 (1.5%) of the patients in the entire group but in none of the 48 patients with significant atheromatous disease in whom modifications in technique were employed.

We conclude that intraoperative ultrasonic imaging is currently the most reliable method of assessing the ascending aorta for the presence of severe atheromatous disease. Modification of standard cannulation and clamping techniques based on ultrasonography may reduce the frequency of stroke related to atheromatous embolization.

*By Invitation