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A technique using soft, flexible catheter stents in performing coronary vein bypass surgery is presented which makes small vessel anastomoses easy and assures accuracy of suture placement with clear identification of the vessel lumen and an anastomosis without stenosis. It provides an essentially bloodless field without having to cross-clamp the aorta. The technique has been used to our complete satisfaction in all patients since we first started vein bypass operations in 1970. A review of the last 205 elective aortocoronary bypass grafts in 100 consecutive patients using this technique reveals a mortality of only 1% and an operative and postoperative myocardial infarction rate of 5%. About half the patients had left ventricular dysfunction with elevated end-distolic pressures, and 68% had had previous myocardial infarctions. Seventy percent of the patients are at present asymptomatic, 24% are improved, and only 4% show no improvement over their preoperative status during follow-up of one to three and one-half years.

The association of cancer of the esophagus with long-standing achalasia signals an especially lethal disease, for in our experience and in a review of the literature this malignant condition has never been diagnosed in time to effect a permanent surgical cure. Although reported over a century ago, the combination of these two diseases occurs more frequently than is generally realized, for cancer is seen in patients with achalasia seven times more often than in the general population [I]. In an attempt to improve the poor prognosis in’ patients with achalasia and carcinoma, we made a study of 225 cases (4 of ours and 221 in the literature) to determine the salient features in early diagnosis, This study suggests that it may be possible to make the diagnosis in time to perform curative resection.

In this condensed overview I have briefly traced the development of ideas and techniques related to coronary artery disease and open and closed heart surgery which have led to the current high level of expertise in coronary artery bypass operations. Because of space limitations (and the personal bias of the author), many important contributions have not been mentioned. The future of myocardial revascularization is impossible to predict at present. Certainly, all aspects of this surgical care will improve as time goes on. This will be balanced by refinements in medical treatment and preventive measures. In the last decade much attention has been focused on attempts to curtail and control the factors which contribute to the development of atherosclerosis. These are hypertension, obesity, high cholesterol and triglyceride levels in the blood, excessive smoking, diabetes and lack of exercise. If these preventive measures result in a significant decrease in coronary artery disease, then the current high demand for coronary artery operations will fall sharply. On the other hand, this may be offset by new techniques in surgery such as the perfection of the artificial ventricle, even an artificial heart, or improved methods for heart and heart-lung transplants. As a result of continuing advances in preventive medicine, medical and surgical care, there is no question that the enormous socioeconomic loss to society from coronary artery disease will continue to diminish. To have been involved in the development of the four phases of cardiac surgery, beginning with extracardiac operations before World War II and continuing up to the present-day open heart procedures at the White Memorial Medical Center and the Los Angeles County Hospital has been a challenging commitment. I consider it a privilege to share the story of the exciting evolution of this surgery, a leading part of the medical explosion of this century.

Subendocardial ischemia with consequent subendocardial necrosis is a frequent cause of death after cardiopulmonary bypass. The problem is caused by an inequity in the oxygen requirements of the subendocardium and the available blood supply. We have developed a means of detecting ischemia early in the postperfusion period. Using an analogue computer, we determine the endocardial viability ratio (EVR). This value may decrease before either systemic or central venous pressure changes. Thus the ratio can reflect early the danger of subendocardial ischemia. Another advantage is that equipment now common in coronary care units can be used to determine the EVR.

This article contains the essence of a report presented to the Council of The American Association for Thoracic Surgery (AATS) by an Ad Hoc Committee on Issues composed of the authors, on October 13, 1976. Because of urgent demand to have this information immediately available, early publication was desirable. However, to have official endorsement of the AATS would have necessitated waiting until April, 1977, the date of the next meeting of the Association. Since this would delay publication of this information for more than one year, it was considered reasonable by the Council that it be published as a free-standing statement of the authors.

From the initial understanding in biblical times that respiration was necessary for life, progress through early medical history was very slow until the Renaissance. In this period and in the 17th and 18th centuries, accurate understanding of human anatomy, the discovery of the circulation of the blood, the isolation of oxygen and carbon dioxide, and the elucidation of the principles of respiration formed the basis for the development of modern human respiratory physiology. The advances in the physiologic sciences during the 19th and 20th centuries provided, at the beginning of World War II, a strong background in the basic understanding of cardiopulmonary function, which had not been generally available during World War I. Application of these physiologic principles by me and my associates in Italy in 1943 and 1944 to the primary surgical care of severely wounded non-transportable casualties with thoracic and thoracoabdominal wounds in forward hospitals resulted in (1) more effective resuscitation; (2) strict limitations in the indications for emergency thoracotomy; (3) the development of the concept of the “wet lung of trauma” (respiratory distress syndrome) in thoracic and other severe injuries; and (4) the development of an effective positive pressure breathing machine to combat hypoxia in severely wounded war casualties. The initial recognition that the lung reflected severe trauma not only to the chest but also to other parts of the body such as the brain and abdomen led to a comprehensive description of the wet lung of trauma, now known as the respiratory distress syndrome. Positive pressure oxygen therapy was initially introduced as a practical method of salvaging patients with the advanced form of this syndrome, that is, pulmonary edema. With the decrease in morbidity and mortality resulting from the introduction of antibiotics in the treatment of pneumonia and with the prevention and better management of heart disease, this form of therapy is becoming more important in managing patients with trauma and those undergoing all types of major surgical operations, especially those involving the heart and lungs. We live in a turbulent age when trauma from automobile accidents, assaults, and other forms of violence is increasing and has become a major problem. Posttraumatic respiratory insufficiency was reported by Moore and his associates [32] as the major cause of death in intensive care units in recent years, confirming our original observations in World War II. During the past two decades physiologic advances and the introduction of better monitoring, cardiac support devices, and elegant, recently perfected, positive pressure breathing machines employed in intensive care units have improved the art. Although great progress in the management of these cases has been made, much needs to be done. This symposium will be devoted to a study of current physiologic and therapeutic approaches to acute cardiopulmonary insufficiency as presented by leading authorities in this country.

The management of the failing myocardium was primarily empirical for centuries, until Withering introduced foxglove (digitalis) in 1785 as an effective medication. Gradually, the medical treatment included, besides digitalis preparations, the use of diuretics to reduce excessive sodium and water retention; limiting salt and water intake; and the administration of drugs to combat vasoconstriction, irregular rhythms, and hypertension. Cardiac surgery emerged for the correction of mechanical lesions while relieving the strain on the myocardium, first in patients with congenital heart diseases and then in those with acquired disease, by closed and then open techniques. In arresting the heart for more precise surgery, the combination of hypothermic and potassium-induced arrest proved to be minimally damaging to the myocardium. However, the search goes on. Mechanical cardiac assist apparatus have been successful in buying time for salvage of patients with failing myocardia refractory to conventional methods. Heart and, more recently, heart-lung transplantations are now having long-term survival. The opportunity for me to present these historical notes is a great privilege , since I have been involved in the problems of heart surgery for more than four decades.

Twenty-five patients with acute gastric volvulus were studied. The two types, organoaxial and mesenteroaxial, are compared with respect to clinical characteristics, diagnosis, pathogenesis and treatment. An understanding of the varied features, including both thoracic and abdominal manifestations, is essential to early recognition and prompt treatment. In addition to Borchardt's triad, this study suggests three important features: (1) minimal abdominal findings when the stomach is in the thorax; (2) a gas-filled viscus in the lower chest or upper abdomen shown by chest radiography (Figure 8), and (3) obstruction at the site of volvulus shown by emergency upper gastrointestinal series. The high incidence of strangulation (28 percent) in this series attests to the urgency of this condition and is a compelling reason for the elective repair of paraesophageal hiatal hernias whenever possible.

During World War II, my associates and I observed for the first time in medical history that casualties with severe brain, thoracic, abdominal, and extremity trauma, who had persistent "wet" respiration (wet lung of trauma), were most difficult to resuscitate, withstood operation poorly, and had the highest mortality. The etiology appeared to be ineffectual cough and persistent bronchopulmonary fluid from hemorrhage, pulmonary transudates resulting from anoxia, airway obstruction, and unknown causes secondary to trauma, some of which have been discovered since then. Our treatment consisted of assisting cough, transnasal tracheobronchial aspiration and oxygenation, bronchoscopy, and tracheostomy. To treat the advanced form, pulmonary edema, I devised an effectual hand-operated intermittent positive-pressure oxygen machine, which has been supplanted by elegant automatic volume- and pressure-regulated devices. Through the use of the intermittent positive-pressure breathing machines, most hospitals have developed thriving departments of respiratory therapy. Better physiological monitoring and use of intermittent mandatory ventilation and positive end-expiratory pressure have improved the care, but our basic principles of treatment are still the standards of respiratory therapy.

Understanding that strangulated diaphragmatic hernia is a thoracoabdominal complex consisting of distinctive gastrointestinal and cardiorespiratory features will facilitate earlier diagnosis and treatment. Strangulated diaphragmatic hernia is a fatal condition unless promptly recognized and surgically treated. The abdominal manifestations of the acute complex include sudden excruciating upper abdominal pain and tenderness, nausea and vomiting, and gastrointestinal bleeding or shock or both. The thoracic portion of the complex is characterized by severe lower chest or substernal pain with radiation to the neck or shoulder. Dyspnea and cyanosis result from a mediastinal shift produced by massive distention from herniated viscera or pleural effusion or both. A gastrointestinal series should be obtained in all patients with crushed chest injuries, multiple rib or pelvic fractures, or severe blows to the lower thorax or upper abdomen before discharge from the hospital. The thoracic approach is preferred for left-sided strangulated diaphragmatic hernia, but the abdominal route may also be satisfactory. The thoracic approach is essential for proper management of strangulated hernia occurring on the right side.

1. 1. A study of eight personal cases and sixteen hospital records of thoracic duct fistula both above and below the diaphragm has been presented. In this series chyle most often formed in the abdominal and combined abdominothoracic regions; next often was in the thoracic region alone, and rarely in the neck and femoral region of the thigh. 2. 2. Trauma and malignant tumor proved to be the most common causes of chylous extravasation although the number of undiagnosed conditions was large. 3. 3. The location of the fistula of the thoracic duct is as important as the etiology in determining the treatment. 4. 4. In the cervical and thoracic regions simple ligation of the duct is generally successful. 5. 5. Below the diaphragm the treatment of chylous fistulas has been generally neglected. The indications for anastomosis of the afferent thoracic duct (and efferent, at times) to the hemiazygos or azygos veins are presented. The author's original technic of this retroperitoneal anastomosis of the thoracic duct to the hemiazygos vein is described. 6. 6. Aspiration of chyle and/or deep x-ray therapy resulted in a high mortality, while ligation and anastomosis procedures can have a low mortality (none in our series) and a high rate of cure. 7. 7. It is believed that the mortality and the rate of permanent cure can be greatly improved. The extension of the surgical treatment, as outlined in this communication, to lesions below the diaphragm should effect this improvement.

D ESPITE the effectiveness of antibacteria agents in peritonitis and pIeuropuImonary infections, the present day incidence of subphrenic abscess has not appreciabIy decreased in our experience, while the empIoyment of antibiotics is steadiIy increasing. In fact, the use of antibiotics has added to the diffIcuIties of diagnosis. We beIieve that the diagnostic probIems wiI1 be simpIified if one considers subphrenic abscess as a thoracoabdomina1 cIinica1 compIex. It is truIy thoracoabdomina1, because there is usuaIIy invoIvement of both regions of the body with a dominance of the thoracic or abdomina1 findings in any given case. Furthermore, this subject has received IittIe attention in the medica Iiterature since the advent of antibiotics. Therefore a review of 125 cases of subphrenic abscess has been made on the Loma Linda University SurgicaI Services at the Los AngeIes County Genera1 HospitaI to study the vaIidity of our concept that subphrenic abscess is a thoracoabdomina1 cIinica1 compIex and to bring us up-to-date on the changing picture with antibiotics.

1. 1. The development and use of the viable pedicled pericardial fat graft in surgery of the trachea and bronchus are presented. 2. 2. Our method of division and closure of the bronchus, reinforced by the “thoracic omentum” in total pneumonectomy and lobectomy has resulted in no instance of bronchopleural fistula before the third week in 292 cases. Late fistula, up until the seventh month, occurred in 2.0 per cent of all the cases. 3. 3. The technic of resection and plastic operations on the trachea and bronchi employed by the authors is reviewed. These include: (1) bronchotomy, (2) flap procedures, (3) lobar transplants, (4) resection and replacement of the tracheal and bronchial walls. 4. 4. A review is made of the clinical application of these technics based on personal experience in twenty-one cases. These procedures are sound and are followed with satisfactory results. 5. 5. A wider application of these technics is possible and will result in the saving of lives and the conservation of pulmonary tissue.

There is no question that Baron Larrey was the first modern military surgeon. The high morale of Napolean's troops, which contributed to the success of his armies, was in a major way dependent on Larrey's superb medical care of the wounded. It was Napoleon's brilliance to recognize this and to give Larrey free rein. Beginning in the Civil War, when ambulances first brought in the wounded to receive surgical care at the Battle of Antietam (1862), down to World War II and the Vietnam War, his principles were increasingly followed by the U.S. Army Medical Corps. In Vietnam a true "flying ambulance," the medical helicopter, was obviously the final perfection of Larrey's ambulance volante. Perhaps his dedicated humanism in the care of the wounded soldier was his best characteristic and the one that should be followed most carefully today. Even in this era of great ethical concerns for the sick and wounded, Larrey's principles set the highest of standards for all.

The progress of esophageal surgery from the beginning of medical history through five historical eras, up to the second half of the 20th century, is reviewed. Progress was slow from the first surgical repair of the esophagus in ancient Egypt in 2500 B.C. until the end of the 19th century, when scientific discoveries made possible the solid beginnings of abdominal surgery. Thoracic surgery followed in the 20th century, with rapid strides in World War II. These wartime advances stimulated an interest in esophageal surgery in the postwar era, when operative techniques became well standardized and surgery of the esophagus was placed on a par with that of other parts of the gastrointestinal tract. Because of the limitations of time and space, much important material has had to be left out. Yet it is hoped that this brief historical overview will put in perspective the important advances of the second half of this century, which will be presented by our distinguished speakers. It has been a privilege for me to have had a part in the development of this type of surgery and to share these ideas with you.

The outstanding scientific and surgical accomplishments of the Second Auxiliary Surgical Group in the Mediterranean Theater of Operations and the 7th Army in World War II were not exceeded by any other group in the United States Army Medical Corps. In the final 921-page report to the Surgeon General with 550 tables, 8801 severely wounded casualties out of a total of 22,000 treated were reviewed. In addition, the major portion of three books on war surgery and over 60 scientific articles were written by this group. The contributions in thoracic surgery that focused attention on physiologic principles and limited the indications for thoracotomy have stood the test of time. The author made the original description of the reaction of the lung to severe trauma of the brain, abdomen, and extremities by the development of "the wet lung of trauma" (RDS), while his introduction of a hand-operated, intermittent positive pressure oxygen respirator to treat the advanced form of this syndrome (pulmonary edema) ushered in a new form of treatment. Long-term, follow-up studies by the author confirm the validity of the physiologic approach to the treatment of thoracic trauma.

Ancient man realized that the chest housed the vital organs of the body for severe thoracic wounds were generally fatal. The vulnerability of the heart influenced the followers of primitive religions to consider the heart as the seat of the soul. Around 3000 B.C. the ancient Egyptian priests believed that to enter the kingdom of heaven, the heart must be weighed against the feather of truth[1] (Fig. 1-1). Many centuries would pass before sufficient physiological knowledge would be gained and surgical techniques developed to provide surgeons the necessary skills to fly in the face of age old superstitions and traditions by deliberately operating upon the organs within the chest. Space limitations restrict the amount of material that may be presented.

A prospective study of cardiopulmonary bypass in adult cardiac surgical patients undergoing similar types of operations compared 50 consecutive perfusions utilizing a clear, balanced, electrolyte-protein prime with 50 consecutive perfusions utilizing a solution containing 1,000 ml. of blood. Significant findings were: The oxygenation and perfusion capabilities during bypass were similar and satisfactory in both groups. The postoperative coagulation studies were essentially the same. The postoperative plasma hemoglobin was 83 mg. per 100 ml. with nonblood prime and 138 mg. per 100 ml. with blood prime; and 12 hour postoperative blood loss was 353 ml. with nonblood prime and 455 ml. with blood prime—22% less in the nonblood prime group. Total blood requirements during hospitalization averaged 1,500 ml. in the nonblood prime group and 3,500 ml. in the blood prime group. The use of nonblood prime and autotransfusions reduces postoperative blood loss, demands on blood bank facilities, risk of serum hepatitis, transfusion reactions, and coagulation abnormalities.

Lung cancer, known by its external appearance as “cerebriform” disease in the 16th century, was finally called carcinoma 3 centuries later with the advent of cellular pathologic analysis. The evolution of pulmonary resection was slow. The introduction of intratracheal anesthesia in the 20th century made possible mass ligation lobectomy and multiple staged pneumonectomy in 1931 and 1932. However, attempts at the excision of lung cancer were not successful until 1933 when Evarts A. Graham performed the first successful one-stage pneumonectomy, demonstrating that the main pulmonary artery could be occluded without reflex changes similar to those caused by massive pulmonary embolism. The fact that his physician-patient not only survived the operation but also lived to a ripe old age practicing medicine showed that surgical cure was possible for the patient with carcinoma of the lung. After this operation, individual ligation techniques for pneumonectomy, segmental resection, lower lobe, and upper lobe lobectomy were introduced. Closure of the bronchus was improved by a virtually leak-proof bronchial closure. This was followed by effective methods of managing the large pleural dead space occurring after lobectomy. Pulmonary resection remains the best method of treatment of lung cancer, so that my classification, which facilitates early diagnosis, can lead to improved results. Because of careful preoperative staging there have been fewer exploratory thoracotomies and longer survival after surgery. The location, size, and extent of the carcinoma are important factors in prognosis. The American Joint Committee classification system has aided in standardizing the reporting of cases. Because of possible occult spread in surgical cases, adjuvant therapy must be considered in postresection cases. Future improvements in long-term postsurgical results will depend more on the advances in adjuvant therapy than on refinements in surgical technique. The development of surgery for lung cancer has been a very absorbing commitment for me for over 40 years. I am grateful for the opportunity to include my interests and contributions in the history of the diagnosis and treatment of this challenging disease.

With the advent of cardiovascular and bypass procedures, aortoesophageal fistula has progressed from the stage of a pathologic curiosity to a treatable lesion. Although the causes of aortoesophageal fistula are varied, a remarkably consistent clinical picture emerges from study of this condition. Chiari's triad of midthoracic pain, sentinel hemorrhage, and a symptom-free interval followed by fatal exsanguination remains the most important clinical finding today. Although contrast esophagography, esophagoscopy, and aortography are important diagnositc aids, immediate left thoracotomy may be the only means of making the diagnosis and saving the patient when hemorrhage is profuse. In most cases (80 per cent of the present series) there is a symptom-free period varying from hours to days from the original sentinel hemorrhage to the final exsanguination. This permits the informed surgeon trained in cardiovascular technics an opportunity to salvage some of these patients. The various methods of aortic and esophageal repair are discussed.

Excerpt Pulmonary histoplasmosis, like pulmonary coccidioidomycosis, may simulate tuberculosis so closely that the differentiation on physical and radiologic examination may be impossible. While co...

Among 489 patients with the diagnosis of bronchogenic carcinoma, there were 291 in whom surgical exploration was carried out. The carcinoma was found in a main bronchus in 71 (24%), in a lobar bronchus in 156 (54%) in a mid-lung zone in 31 (11%) and in a subpleural location in 33 (11%). The highest rate of resectability (94%) was among the 31 mid-lung carcinomas, while the subpleural group were the least favorable. The greatest rewards in resectability were thus found in the group of patients in whom bronchoscopy is always negative, the diagnosis being made by following up the suspicious shadow seen on the chest roentgenogram by exploratory thoracotomy. Operative mortalities were about the same in the four groups, but early postoperative results were best in the group with mid-lung cancer (86% of those surviving surgery being alive after one year). The "negative" chest film from previous examinations, when compared to the x-ray under consideration, supplies the key information in making an early diagnosis of lung cancer. Therefore, this film should be considered as one of the patient's most valuable possessions. If storage facilities in an x-ray department are limited, such films should be given to each patient to keep for himself.

Introduction This report records the successful resuscitation of a patient who had a cardiac arrest in the postoperative room one hour following the completion of a right pneumonectomy for pulmonary tuberculosis at Olive View Sanatorium, on Nov. 11, 1954. The patient had sudden cessation of all vital signs due to a massive hemorrhage from the right main pulmonary artery and was considered dead. The availability of trained personnel and proper facilities made immediate religation of the pulmonary artery and cardiac resuscitation possible. The patient left the hospital with no neurologic sequelae. Cardiac resuscitation after ventricular fibrillation or cardiac arrest occurring in the operating room is now a well-established procedure, which has been successfully performed on many occasions. In at least two instances successful resuscitation of a patient suffering from ventricular fibrillation outside the operating room has been reported.2-4We have been unable to find a similar report of the

SUMMARY 1) Pulmonary resection has a definite place in the surgical therapy of pulmonary tuberculosis in salvaging otherwise hopeless cases. 2) With the exceptions cited, we prefer thoracoplasty to lobectomy and pneumonectomy in the treatment of pulmonary tuberculosis. This point of view is based on the fact that the mortality from thoracoplasty is considerably lower than pulmonary resection and to date, the late results of resection seem to offer no better chance of permanent cure. 3) When thoracoplasty fails, the following measures are considered before performing pulmonary resection: (1)Revision thoracoplasty. (2)Creation of extrapleural space and packing. (3)Cavity drainage. (4)In some cases, no further surgery. 4) Primary pulmonary resection is preferred to thoracoplasty for: (1)Lower and middle lobe cavities. (2)Tuberculomata and blocked cavities. (3)Persistent bronchostenosis. (4)Symptomatic bronchiectasis. 5) From the point of view of the pathological pulmonary changes, the type of disease most amenable to lobectomy and pneumonectomy is that characterized by fibroid and caesating lesions of the lung in which the mode of spread is principally by way of the bronchus. Since the prognosis following thoracoplasty in this type of lesion is also good, it is unusual that the surgeon is confronted with the problem of primary pulmonary resection. 6) Primarily, hematogenous or lymphogenous disseminated pulmonary tuberculosis is a contra-indication to resection, as these types of disease are progressive and removal of one part of the lung does not alter the course of the lesions in the remaining part of the lung. 7) If thoracoplasty is unsuccessful, then revision thoracoplasty, plombage, and cavity drainage should be considered before lobectomy or pneumonectomy is performed. Pulmonary resection is to be preferred to cavity drainage, if the pulmonary capacity of the patient permits. 8) In selecting any case for lobectomy or pneumonectomy, the surgeon must be certain that the patient has sufficient pulmonary reserve. Contralateral pleural thickening and diaphragmatic paralysis, along with fibrosis, calcification, and emphysema of the lung are the most important conditions in lowering the patient's breathing capacity. 9) In the surgical management of over 1,000 cases of pulmonary tuberculosis, we have performed lobectomy and pneumonectomy in 40 cases with early and late mortality of 27.5 per cent. In approximately an equal number of cases, resection was indicated but not performed for various reasons. This represents a very hopeless group of cases where for the most part, thoracoplasty had failed, and no other treatment would cure. 10) Lobectomy and pneumonectomy are indicated in many patients where thoracoplasty has failed or obviously will not succeed. The actual number of patients upon whom it is possible to perform pulmonary resection is greatly reduced because of these factors: (1) contralateral tuberculosis; (2) instability of the contralateral lesion, and (3) low pulmonary reserve. 11) We are by no means satisfied that the indications we have presented will stand the test of time. Our point of view lies somewhere between the eager advocates for pulmonary resection, whose enthusiasm has not yet been supported by satisfactory long-time results, and those who roundly condemn lobectomy and pneumonectomy for pulmonary tuberculosis. 12) It is becoming steadily more evident that it is not technical skill alone that will lead to a higher percentage of permanent arrests in pulmonary tuberculosis. The basic tendency of the disease in each particular case is variable. Thus, the more able we become in recognizing the type of pulmonary involvement, the more accurately we will place lobectomy and pneumonectomy in their proper relationship with other therapeutic procedures.