THE TREATMENT OF PULMONARY BY SURGICAL RESECTION · tuberculosis treated by surgical resection....

17
216 THE TREATMENT OF PULMONARY TUBERCULOSIS BY SURGICAL RESECTION By WALTER L. PHILLIPS, M.R.C.P.(Lond.), F.R.C.S.(Eng.). Thoracic Surgeon, Groote Schuur Hospital; Thoracic Surgeon, City Hospitalfor Infectious Diseases, Cape Town Many years have passed since surgical treat- ment for cases of pulmonary tuberculosis was first instituted, and with this lapse of time the simple surgical measures first employed have been supple- mented by major thoracic procedures. Recently major surgical operations such as pneumonectomy and lobectomy have been performed. The successful advent of these procedures in the field of therapy for pulmonary tuberculosis has largely been due to the improvement in surgical tech- nique, the introduction of special anaesthesia and the use of specific antibiotics. Pulmonary resection has for many years been a standard operation. Its place in the treatment of cases of tuberculosis resulted from the fact that when pulmonary lobes which had been removed for bronchiectasis were histologically examined, a coincident tuberculosis was often discovered, and yet in these cases the incision generally healed by first intention and the post-operative course was uneventful. Removal of affected or diseased tissue is a surgical axiom, and thus deliberate attempts were made to resect the tuberculous lung tissue. Many disastrous sequelae, however, resulted in the abandoning of resection as a line of treatment, until the more recent advances in anaesthesia and the newer antibiotics reduced the hazards of this method. A very different picture is seen today. This paper gives a report on 50 cases of pulmonary tuberculosis treated by surgical resection. Pneu- monectomy and lobectomy are discussed, as well as segmental resection, which refers to the removal of an anatomical segment of a lobe. Pleurectomy is also described, as the pleural mem- branes are often involved in the tuberculous pro- cess or are affected by ineffective attempts at treatment. In many cases part of the pleural lining has been resected, and in some cases removal of the entire pleural covering has been necessary. Types of Tuberculous Pulmonary Disease The indications for surgical resection should be clearly outlined. Unfortunately the surgeon is usually only asked to treat the patient when other measures have failed, and the treatment is far too sharply divided into medical and surgical stages. Many accepted views and lines of treatment re- quire to be re-assessed, and many of the older medical and surgical methods will have to be per- manently discarded. It is as important to know when medical treatment should be supplanted by surgery as it is to realize when surgical therapy is primarily indicated. We shall consider pulmonary tuberculosis under two headings in order to elaborate on this theme. The Temporary Type of Disease This group includes those cases in which the pulmonary lesion heals, leaving only a small cal- cified or fibrosed area with relatively unimpaired respiratory function. Bed rest, antibiotic treat- ment, pneumothorax and pneumoperitoneum therapy are the methods usually adopted. Oc- casionally minor surgical operations such as thoracoscopy and adhesion section, and phrenic paralysis are used in conjunction with the above. Thus the patient is rendered non-infectious, the pulmonary function is restored and at no stage has he been exposed to dangerous complications. At. the termination of treatment careful medical and radiological observation should be maintained. The Permanent Type of Disease These cases show permanent damage to the entire lung or portion of it, and restoration of normal function is not possible: Any temporary form of treatment, even though it may render the patient non-infectious, will leave him with im- paired pulmonary function and with an increased susceptibility to dangerous sequelae. Generally at this stage the patients were referred for surgical treatment and the operation of thoracoplasty and apicolysis was performed. It was recognized that where permanent damage to the lung had oc- curred a permanent form of collapse therapy was indicated. Resection is advocated as an extension of this principle, and if the patient's general condition is satisfactory the permanently damaged, useless and dangerous lung tissue should be removed. It is obvious that the surgeon should collaborate with the physician at the primary institution of treat- ment. copyright. on March 30, 2020 by guest. Protected by http://pmj.bmj.com/ Postgrad Med J: first published as 10.1136/pgmj.27.307.216 on 1 May 1951. Downloaded from

Transcript of THE TREATMENT OF PULMONARY BY SURGICAL RESECTION · tuberculosis treated by surgical resection....

Page 1: THE TREATMENT OF PULMONARY BY SURGICAL RESECTION · tuberculosis treated by surgical resection. Pneu-monectomy and lobectomy are discussed, as well as segmental resection, which refers

216

THE TREATMENT OF PULMONARY TUBERCULOSISBY SURGICAL RESECTION

By WALTER L. PHILLIPS, M.R.C.P.(Lond.), F.R.C.S.(Eng.).Thoracic Surgeon, Groote Schuur Hospital; Thoracic Surgeon, City Hospitalfor Infectious Diseases, Cape Town

Many years have passed since surgical treat-ment for cases of pulmonary tuberculosis was firstinstituted, and with this lapse of time the simplesurgical measures first employed have been supple-mented by major thoracic procedures. Recentlymajor surgical operations such as pneumonectomyand lobectomy have been performed. Thesuccessful advent of these procedures in the fieldof therapy for pulmonary tuberculosis has largelybeen due to the improvement in surgical tech-nique, the introduction of special anaesthesia andthe use of specific antibiotics.

Pulmonary resection has for many years been astandard operation. Its place in the treatment ofcases of tuberculosis resulted from the fact thatwhen pulmonary lobes which had been removedfor bronchiectasis were histologically examined, acoincident tuberculosis was often discovered, andyet in these cases the incision generally healed byfirst intention and the post-operative course wasuneventful. Removal of affected or diseased tissueis a surgical axiom, and thus deliberate attemptswere made to resect the tuberculous lung tissue.Many disastrous sequelae, however, resulted in theabandoning of resection as a line of treatment,until the more recent advances in anaesthesia andthe newer antibiotics reduced the hazards of thismethod.A very different picture is seen today. This

paper gives a report on 50 cases of pulmonarytuberculosis treated by surgical resection. Pneu-monectomy and lobectomy are discussed, aswell as segmental resection, which refers to theremoval of an anatomical segment of a lobe.Pleurectomy is also described, as the pleural mem-branes are often involved in the tuberculous pro-cess or are affected by ineffective attempts attreatment. In many cases part of the pleurallining has been resected, and in some cases removalof the entire pleural covering has been necessary.

Types of Tuberculous Pulmonary DiseaseThe indications for surgical resection should be

clearly outlined. Unfortunately the surgeon isusually only asked to treat the patient when othermeasures have failed, and the treatment is far toosharply divided into medical and surgical stages.

Many accepted views and lines of treatment re-quire to be re-assessed, and many of the oldermedical and surgical methods will have to be per-manently discarded. It is as important to knowwhen medical treatment should be supplanted bysurgery as it is to realize when surgical therapy isprimarily indicated.We shall consider pulmonary tuberculosis under

two headings in order to elaborate on this theme.

The Temporary Type of DiseaseThis group includes those cases in which the

pulmonary lesion heals, leaving only a small cal-cified or fibrosed area with relatively unimpairedrespiratory function. Bed rest, antibiotic treat-ment, pneumothorax and pneumoperitoneumtherapy are the methods usually adopted. Oc-casionally minor surgical operations such asthoracoscopy and adhesion section, and phrenicparalysis are used in conjunction with the above.Thus the patient is rendered non-infectious, the

pulmonary function is restored and at no stagehas he been exposed to dangerous complications.At. the termination of treatment careful medicaland radiological observation should be maintained.

The Permanent Type of DiseaseThese cases show permanent damage to the

entire lung or portion of it, and restoration ofnormal function is not possible: Any temporaryform of treatment, even though it may render thepatient non-infectious, will leave him with im-paired pulmonary function and with an increasedsusceptibility to dangerous sequelae. Generallyat this stage the patients were referred for surgicaltreatment and the operation of thoracoplasty andapicolysis was performed. It was recognized thatwhere permanent damage to the lung had oc-curred a permanent form of collapse therapy wasindicated.

Resection is advocated as an extension of thisprinciple, and if the patient's general condition issatisfactory the permanently damaged, useless anddangerous lung tissue should be removed. It isobvious that the surgeon should collaborate withthe physician at the primary institution of treat-ment.

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May i95i PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection

Indications for Pulmonary ResectionThe lung can be divided into a number of

anatomical segments, each segment having its ownbronchus, artery and vein. This implies that anyone segment of any anatomical lobe of either lungshould be regarded as an anatomical entity, whichcan be removed from the lobe through a plane ofcleavage which is avascular and free of bronchialtributaries.

Extensive Unilateral and Unilobar TuberculosisIt has been previously stated that resection is

indicated in any case showing permanent dis-organization of a lobe or of the entire lung. In thepast, artificial pneumothorax was employed as theline of treatment for these patients and a goodpneumothorax was often obtained, though an ad-hesion section was sometimes necessary.The pneumothorax in extensively diseased cases

invariably led to an atelectasis of the affected part.Examination of sputum was usually negative fortubercle bacilli, but the patient was deemed for-tunate if he escaped any complications such aspleurisy or empyema. After three to five years ofthis treatment the pneumothorax was usuallyabandoned, and with the aeration of the lung thecavities reappeared and the sputum becamepositive again. Aeration was often incomplete,gross mediastinal displacement was seen and verysoon symptoms of bronchiectasis of the affectedlung and emphysema of the other lung weresuperimposed on the already gloomy picture.Some patients refused to give up artificial

pneumothorax therapy as they had felt-so wellduring the course.

Frequently a pneumothorax was not obtainableand a thoracoplasty was performed. This majorprocedure not only carries with it a mortality ratea little higher than that for a lobectomy or pneumo-nectomy, but the diseased tissue which is retainedin the chest remains as a possible site for thedevelopment of more advanced pathology.

Pulmonary and Endobronchial TuberculosisEnddbronchial tuberculosis with early, re-

versible, pulmonary parenchymal disease is ar&absolute contraindication to collapse therapy.This view applies even more strongly to cases ofadvanced disease. Complete obstruction of thebronchus, with the complication of lung abscessformation, may follow on the induction of anartificial pneumothorax.

Endobronchitis of the main bronchus is usuallyassociated with disorganization of the lung, andthis combination provides a clear indication forpneumonectomy.Where a tuberculous ulcer in the main bronchus

is associated with disease of one lobe and the

other lobes appear normal, radiographically, anattempt should first be made to treat the locallesion in the bronchus. It is always important toconserve healthy lung tissue.Lobectomy is indicated if the bronchial lesion

affects only one lobe and if that lobe is partly orwholly involved by the tuberculous process.

Pre-operative bronchoscopy to determine thepresence of tuberculous endobronchitis is ex-tremely important. The resection of a lobe in-volves division of the bronchus, and if this divisionoccurs across an ulcerated site there will becontamination of the pleural cavity.

Pre-operative bronchoscopy has been adopted asa routine measure by our thoracic surgical unit.A word should be said about the case of tubercu-

losis with a positive sputum which presents with amain bronchial stenosis. The stenosis is normallynot complete and the lung appears to have normalfunction with no radiographic evidence of disease.The patient should be closely observed and theusual antibiotics should be administered. Apneumonectomy should be performed if any signof pulmonary involvement ensues.

Failed Pneumothorax Collapse TherapyPneumothorax collapse therapy may fail com-

pletely owing to the presence of widespread ad-hesions attaching the lung to the chest wall, andthus resection of the affected lung tissue becomesthe treatment of choice.

In many cases, however, a pneumothorax maybe obtained, but dense extensive indivisible ad-hesions remain attaching the lung to the thoraciccage. If an unclosed cavity still exists the pneumo-thorax should be immediately abandoned and re-section should be carried out. The maintenance ofsuch a pneumothorax invites disaster, as theadhesions may be torn off the lung over the cavityarea with inevitable infection of the pleural space,in the shape of an obliterative pleurisy or anempyema.

Occasionally after a pneumothorax induction allthe cavities appear to be closed, but there is per-sistence of large, indivisible adhesions. Thesecases are similarly potentially dangerous.A pneumothorax should not be maintained in

cases irrespective of the presence of adhesions ifan underlying cavity commences to enlarge, as thedistension will eventually lead to bursting of thecavity.A patient may continue to produce a positive

sputum even though the pneumothorax is satis-factory, and the disease appears to be undercontrol. Bronchoscopy must be supplemented bybronchography before the decision can be reachedthat all is well in the collapsed lobe. In one of thecases under review, bronchography revealed the

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POSTGRADUATE MEDICAL JOURNAL

presence of a large cavity in a lobe which was be-lieved to be satisfactorily collapsed.

Artificial pneumothorax should only be em-ployed as a means of treatment if it can beadequately performed and if the indications for itare exact. It has been our experience that toomany inefficient pneumothoraces have been main-tained. Unfortunately far too often the unsatis-factory pneumothorax has been abandoned to bereplaced by an equally useless pneumoperitoneumwith phrenic paralysis.

Failed ThoracoplastyEach year witnesses the return of a number of

thoracoplasty cases owing to the presence of apersistently positive sputum. Some cases have aresidual cavity easily discernible on ordinary films,though usually special radiographic examinationsare essential. Tomography is helpful in manycases but may not entirely exclude the presence ofcavitation.

Bronchography has proved extremely important,as in many cases it has demonstrated the presenceof bronchiectasis in parts of the lung which hadbeen previously regarded as normal. Thisbronchiectasis apparently develops after thethoracoplasty operation.

There are many reasons why thoracoplasty maynot be considered the operation of choice. Ifresidual cavitation and bronchiectasis persistafter thoracoplasty the resection which may thenbe indicated becomes a more difficult procedure.Many authors have reported a high rate of sputumconversions and cavity closures following onthoracoplasty operations. Their results vary from6o to 8o per cent. of successes. In my experienceof a large number of thoracoplasty operations withapicolysis, although every attempt has been madeto conform to the techniques described by theauthors, the percentage of conversions has beenunder 6o per cent. Apart from the risks of theactual operation the complications are many, andhospitalization and rehabilitation is of longduration.

In oUr thoracic unit the operation of thoraco-plasty is employed to close the spaces which mayremain after lung resection, in order to preventoverdistension emphysema. Resection has re-placed thoracoplasty in the surgical therapy ofpulmonary tuberculosis.

Previously, while the European patient acceptedthe rationale of the thoracoplasty operation, theColoured and African patients remained recal-citrant and could not be persuaded to undergothis procedure. Pulmonary resection, which isdesigned to remove the tuberculous lung tissue and

involves a shorter convalescence, is gladly acceptedby both European and non-European patients.

Lower Lobe DiseaseLower lobe'disease has, in the past, shown a

poor response to treatment, possibly due to theactivity which occurs continuously in this area.The lower lobes are never in a state of completerest as they are affected by the movements of thediaphragm or by the transmitted movements of theheart.Pneumothorax and pneumoperitoneum treat-

ment usually fails in cases of lower lobe disease.In most of these patients the disease exists in theapex of the lower lobe or the so-called ' superiorsegment' described by American authors, andwhen cavitation is present it appears radiographic-ally to be in the region of the pulmonary hilum.Cavitation in the apex of the lower lobe is generallyassociated with dense, indivisible adhesions be-tween the lung and the paravertebral sulcus, so itis not surprising that a pneumothorax is contra-indicated.

Tuberculoma of the LungTuberculoma of the lung may not be diagnosed

prior to operation, but if a history of tuberculosishas been obtained the nature of a rounded pul-monary tumour should be suspected. Thesetuberculomata are often well encapsulated, and inmany cases the radiographic appearance is that ofa tuberculous abscess containing a central mass ofnecrotic tissue. This lesion may be localizedenough to permit of a segmental resection of lungtissue.

Bronchopleural FistulaThe presence of a bronchopleural fistula in

pulmonary tuberculosis usually signifies irreparablelung damage, associated with a large tuberculousempyema and great thickening of the pleurallining. The general condition of the patient isinvariably serious and the prognosis is grave.

If the bronchopleural fistula is small, some im-provement may be obtained by -external under-water drainage of the empyema. If the generalcondition of the patient can be improved it maybe possible to resect the lung as well as the entirepleural membrane. This procedure, which hasbeen described by Sarot, includes not only apneumonectomy but also removal of the entireparietal pleura, and is considered to be of value bythe author. Haemorrhage is usually quite con-siderable and adequate quantities of blood shouldbe available for transfusion during the operation.

Resection of the PleuraAt the termination of artificial pneumothorax

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May 1951 PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection 219

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ee:.i.. ,,3^s, ..FIG. I.-Normal bronchial distribution in left lung at

end of left artificial pneumothorax treatment. Con-clusion is that treatment can be abandoned withoutfear of complications as lung expands.

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FIG. 2.-Extensive tuberculous disease of right lungwith tracheal displacement to right. Right artificialpneumothorax obtained-surprisingly. This methodof treatment definitely contraindicated in such case,as right lung permanently disorganized anddangerous complications are inevitable.

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FIG. 3.-Complete atelectasis of right lung followingartificial pneumothorax for extensive infiltrationand cavitation. No sputum. Large pleural effusioncontaining tubercle bacilli. Right lung per-manently disorganized and dangerous complicationsfollowed this treatment,

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FIG. 4.-Following febrile illness and cough, patientfound to have tubercle bacilli in sputum. Lungparenchyma normal radiographically and clinically.Bronchography confirmed stenosis ofmain bronchusseen -at bronchoscopy.

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220 POSTGRADUATE MEDICAL JOURNAL May 1951

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FIG. 5a.-Unilateral disease of upper lobe treated byleft artificial pneumothorax. Indivisible broadapical adhesions. Pneumothorax should be aban-doned or modified by additional treatment.

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FIG. 5b.-Following extrapleural stripping and fenestra-tion, left upper lobe retracted well but cavity re-mained open. Combined intra- and extra-pleuralpneumothorax thus proved unsuitable and re-section was subsequently necessary.

····:.i:.:::iI l~s se~l6~~n· . : ·::i: :.^;''s..':.:!:}8- - ^- S , wE} ~I DE 8- g~~~~~~~~~~~~i; ... ::....::''}:'i:: 8 :i- l-.e8r-Rl-l - ..... ....: .e .3F

- s!>.i~~~~~~i. .. -sI;;|>w- '~~~~~~:.:::i:^SR ....... 2-:.:.:E--S-e

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FIG. 6.-Tuberculous cavitation of right upper lobe.Pneumothorax failed and equally unsuccessful re-sult with pneumoperitoneum and phrenic paralysis.Lobectomy produced excellent result.

treatment the underlying lung may show noevidence of re-expansion and, in many cases, thethick rigid layer of visceral pleura may completelyincarcerate the lung. Re-expansion of the lung isimportant, as the pulmonary disease may bequiescent. If re-expansion does not occur, over-expansion of the opposite side with resultingemphysema may follow, seriously handicappingthe patient by dyspnoea and exposing him to therisk of the development of a cor pulmonale.Re-expansion of the underlying lung may followon decortication of the pleural lining.One must also consider the question of a

tuberculous empyema, which can be regarded as acold abscess in the pleural cavity. These patientshave usually undergone repeated chest aspirations,the pus obtained from the cavity sometimes show-ing the presence of tubercle bacilli and sometimesbeing sterile.

X-ray examination of the chest should be re-peated when the pleural cavity has been completelyemptied by aspiration. If any query arises as tothe state of the lung parenchyma, bronchographyshould be performed. If all the sputum tests arenegative and the lung appears unaffected radio-graphically the entire pleural lining can be removed.The. haemorrhage from the chest wall after thestripping is usually controllable. After this de-cortication the underlying lung tissue, if healthy,will re-expand and obliterate the pleural space.

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May 1951 PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection 221

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FIG. 7a.-Thoracoplasty and apicolysis for infiltrationand cavitation of right upper lobe. Two years latersputum became positive and triangular-shapedcavity became visible under medial end of clavicle.

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FIG. 7b.-Following right upper and middle lobectomyunder previous thoracoplasty all the symptomsdisappeared. Compressed upper lobe containedlarge chronic tuberculous cavity. The lower lobeexpanded well after resection.

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FIG. 8.-Infiltration and cavitation of lower lobe ofright lung. Pneumothorax failed. Ideal case forresection.

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FIG. 9.-Large cavity stated to be situated in hilarregion of left lung. In fact cavity is in apex of lowerlobe. Pneumothorax, phrenic paralysis andpneumoperitoneum unsuccessful. Resection in-dicated.

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222 POSTGRADUATE MEDICAL JOURNAL May 1951

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FIG. Ioa.-Large rounded shadow in mid-zone of leftlung, believed to be a carcinoma. Resectionshowed this to be a tuberculoma.

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FIG. Iob.-Left artificial pneumothorax treatment fortuberculous cavity. Pneumothorax maintained forthree years. Cavity visible in second interspace re-appeared when pneumothorax abandoned. Re-section necessary. Specimen showed encapsulatedfibro-caseous focus suggestive of breaking downtuberculoma.

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FIG. iI.-Tuberculous empyema complicating artificialpneumothorax. Pulmonary disease quiescent andpatient required pleurectomy. Lung re-expanded.

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FIG. 12.-Thoracoplasty performed for left upper lobetuberculous cavitation. Two years later repeatedsevere haemoptyses occurred. Bronchographyshowed extensive bronchiectasis of both lobes. Noevidence of active tuberculosis in upper lobe. Filmshows appearances after pneumonectomy.

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May I951 PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection

If the empyema is associated with lung diseaseit may be necessary to resect the affected lobe oreven the entire lung in conjunction with the pleuralresection.

Tuberculosis and CarcinomaThe incidence of carcinoma is not higher in

tuberculous patients than in the non-tuberculouspopulation.

Resection of the lung is a matter of urgency incases which present the two conditions simul-taneously. The general condition of the patientshould be carefully assessed as a lobectomy may bea less hazardous procedure than a pneumonectomy.

Bronchiectasis Complicating TuberculosisBronchiectasis may give rise to symptoms which

necessitate surgical treatment even though thetuberculous disease has become quiescent spon-taneously or as a result of treatment. Thusresection of the upper lobe may be indicated incases of arrested chronic fibroid tuberculosis ofthe upper zone if the residual bronchiectasis isgiving rise to adverse symptomatology.

Stricture of the bronchus may result fromulceration of tuberculous lymph nodes. Secre-tions are retained in the lobe beyond the strictureand the resulting bronchiectasis is best treated bypulmonary resection.

Atelectatic pulmonary tissue is often a pre-cursor of bronchiectasis. The so-called ' idealpneumothorax cases ' included those cases inwhich the diseased area was completely atelectatic,while the normal portion of the lung remainedaerated but partly compressed. Patients in thiscategory remained well with a negative sputumduring the time that the pneumothorax was main-tained.

Various authorities have stated that tubercu-losis heals with atelectasis. This is often true, theproviso being that the atelectasis often results inbronchiectasis, When this ' ideal pneumothorax'is abandoned new symptoms may develop as thelung re-expands. The cough, sputum productionand haemoptyses of bronchiectasis soon provide apicture similar to that caused by the tuberculosis.The patient is therefore in the unhappy position ofrequiring a resection of the lobe of the lung at theend of a three- to five-year course of treatment.Much time and invalidity would have been sparedhim had the lobectomy been performed initially.

Uncontrollable HaemorrhageResection of lung tissue may be urgently called

for if an uncontrollable haemorrhage occurs. Ifthe usual measures of controlling haemorrhagehave failed the patient's general condition may bevery poor. The decision to perform a resection

thus becomes a difficult one and many transfusionsmay be necessary. The extent of the tuberculousinvolvement must be carefully assessed as the in-haled blood clot may radiographically resemble' tuberculous infiltration,' and this may suggestthat more extensive disease exists than is actuallythe case. Fortunately, although the occurrence ofhaemorrhage is frequent, the problem of urgentresection does not often arise.

Scarcity of Hospital AccommodationThe scarcity of hospital accommodation pro-

vides a very real and important indication forlobectomy in a social context. The world-wideshortage of hospital beds inclines one to favourmethods which set patients on the road of re-covery shortly after the institution of the treat-ment. Pulmonary resection is a clear example ofthis and not only does it allow of a speedier re-covery for the individual patient, but it ensuresadequate treatment for a very much larger numberof cases as more hospital beds become available.

Pre-Operative Assessment of the PatientPulmonary resection is a major operative pro-

cedure and therefore the general condition of thepatient and the indications for surgery must becarefully assessed before this line of treatment isadopted. The patient should be under observationby the surgeon for two months prior to operation,during which time a careful record should be keptof the temperature, the body weight and the bloodsedimentation rates. A record should be obtainedof the reaction to exercise. The patient should beup for at least six hours each day, allowing definitetime periods for slowly walking about. At thecommencement of the observation period heshould be walking about for five minutes a day,increasing daily to two hours walking at the end oftwo months.

This is contrary to the accepted views whichstress pre-operative rest. During any type ofpulmonary resection an enormous physical strainif placed on the circulatory and respiratory systemsso the patient, and the operation may last severalhours. One would not expect anyone to completea few hours of strenous exercise after a long periodof bed rest, and similarly no patient, in my opinion,is in a fit state to undergo this operation afterhaving been confined to bed for a few months.The operation should be postponed if there is

evidence clinically or radiographically that thedisease is in an active phase. Radiographic in-vestigations at four-weekly intervals should becarried out during the observation period, and thefilms should be compared with those taken pre-viously. Any sign of extending infiltration is acontraindication to operation. One must re-

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member that the disease is usually more extensivethan is demonstrated by the X-ray films.Three special investigations should always be

performed prior to resection.

Vital Capacity as Measured by Means of a Spiro-meterA vital capacity adequate for a small person may

be completely inadequate for a large individual.A resection should not be performed if the vitalcapacity is under I,500 cc. in a patient whoweighs 125 lb., or under i,8oo cc. in a patientweighing from 125 to I75 lb., or under 2,000 CC.in those patients weighing more than 175 lb. It isnot enough to estimate the vital capacity in theusual manner, which measures the amount of airexhaled after a maximum inspiration.Many individuals have a vital capacity of almost

2,000 CC. when emphysema or bronchospasm ispresent. They may take I to 20 seconds to blowall this air into a spirometer. After about fiveseconds they may strain and exhale a portion oftheir residual air, and it is this extra amount whichleads to the false reading of about 2,000 CC.A reasonably accurate reading of vital capacity

will be obtained if the patient is requested to ex-hale as rapidly as possible and if the examiner dis-regards any air exhaled after the initial period offive seconds.The discovery of a low vital capacity is a definite

contraindication to resection as the surgical pro-cedure will diminish it still further even up to thepoint of respiratory insufficiency.

BronchographyBronchography should be performed about a

month before the operation. We know that thetuberculous disease is usually more extensive thanis shown by ordinary X-ray examination, but theinstillation of iodized oil may do more than merelyconfirm this, as it will show coexistent areas ofcavitation and bronchiectasis.As a total filling of the affected lung is necessary

the investigator must exercise both skill andpatience. Bronchograms will indicate the extentof the tuberculosis and thus the magnitude of theresection, and will also demonstrate the exactlocalization of the disease process. Ordinaryiodized oil eventually percolates into the alveoli.If the oil is thickened with sulphathiazole or sul-phanilamide powder in the proportion of 5 gm. to20 cc. of oil, the patient is usually able to ex-pectorate all the mixture within a short space oftime.Some authorities believe that the iodized oil

leads to a spread or flare-up of the tuberculousdisease, but this has not been my experience.The technique used in bronchography is not

important as long as all the affected lung is filledand good X-ray films are secured. The exactlimits of the lung can be outlined by broncho-graphy. Lesions which may appear intrapulmonaryon ordinary films may be shown to be extra-pulmonary, i.e. in the pleural space or membranes,on bronchography.

BronchoscopyInspection of the bronchial tree should always

be carried out to exclude the presence of ulceration.Division of a bronchus at the site of an ulcer willlead to the breakdown of the line of repair andsubsequent contamination of the pleural cavity.

Radiographically the disease may appear to belocalized to one particular lobe, the remaining lobesappearing unaffected. Findings at bronchoscopymay complicate the issue by revealing tuberculousulceration of the bronchi supplying the other lobes.Consequently the necessary resection may bewider than was originally contemplated.

If ulceration in the region of the carina isdemonstrated all ideas of pulmonary resectionmust be temporarily abandoned.

Surgical TechniqueThe programme for the treatment of tubercu-

losis by pulmonary resection may conveniently bedivided into four stages.

i. The period of preparation.2. The operation of resection.3. The post-operative period.4. The period of rehabilitation.The final stage is beyond the scope of this

article as it deals with the patient who is sufficientlyrestored physically to be sent to a sanatorium.After observed and adequate conditions of rest anddiet and the performance of graduated exercises inthe sanatorium he may be returned to his normalplace in society.

Pre-Operative PreparationThe patient should receive 1 gm. injections of

streptomycin intramuscularly morning and even-ing for I4 days prior to operation. This is designedto prevent any spread of the disease during thepre-operative and operative periods of the treat-ment. Since the introduction of streptomycinsurgical procedures are rarely followed by diseaseextension.

P.A.S. usage must be controlled as it has beenshown that it leads to a bleeding tendency. If thepatient has been receiving P.A.S. therapy it shouldbe discontinued for the 14 days before operation.If necessary this treatment can be resumed afterthe recovery of the patient.Twenty-four hours before the operation peni-

cillin in doses of 500,000 units should be combined

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May 195I PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection 225

I:

·i·'"9i.B118111sP.·13s.aB..?F..i

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FIG. 13.-Stricture of stem bronchus immediately be-low upper lobe bronchus on right side. Bronchiec-tasis of lower lobe. Examination following lobec-tomy showed cause of stricture to be due totuberculous gland.

.. .: eeiieeS 4

FIG. 14a.-Following right artificial pneumothorax,atelectasis of upper lobe occurred. In spite ofabsence of symptoms lobectomy was indicated asthis lobe failed to aerate when the pneumothoraxwas being abandoned.

"iiiiiii,i··:..

:ii

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FIG. 14b.-Similar case except that in spite of atelectasisof upper lobe of left lung this also showed presenceof cavities in this collapsed lobe. Following lobec-tomy the specimen showed numerous caseatingareas.

sr-*:;??·a*;r?.;

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ir

FIG. 15.-Infiltration and cavitation at first confined toupper lobe of right lung. Disease extended intolower lobe during period of observation. Pneumo-thorax failed. Resection is absolutely contra-indicated at this stage. Pneumoperitoneum andright phrenic paralysis is indicated as well as use ofstreptomycin and P.A.S.

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226 POSTGRADUATE MEDICAL JOURNAL May 1951

:·I.

··::lb:"'

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Fi,o. i6a.-Infiltration and cavitation of the lower lobeof left lung. After pneumothorax the cavities in theapex of the lobe remained open.

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FIG. i6b.-Following left lower lobectomy the upperlobe expanded, almost filling pleural space. Healingrapid and uncomplicated.

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FIG. I7.-Post-pneumonectomy thoracoplasty becauseof rapid absorption of pneumothorax and move-ment of mediastinum towards operation side.Ribs No. 2 to No. 7 removed.

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FIG. I8.-Bilateral disease. Right upper lobe removedand disease in left mid-zone unchanged. Filmshows residual pneumothorax and effusion followingupper lobectomy, no attempt being made to emptythe pleural space completely.

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May I95 I PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection

with the streptomycin administration. These twoantibiotics are of vast importance in the pre-vention of pyogenic infection and in the retardationof the activity of the tuberculous process.

The Operation of Pulmonary ResectionPremedication of morphine sulphate, i gr., or

omnopon, j gr., is administered half an hour beforethe operation. The nasopharynx and throat aresprayed with a solution of io per cent. cocainehydrochloride, the patient having been given acocaine sensitivity test at some previous time. Asmall quantity of pentothal sodium is injected intothe intravenous drip saline, which should be setup before the operation.The anaesthetist then passes an intratracheal

tube, packs off the pharynx, and pentothal andcurare anaesthesia is commenced, the lungs beingventilated by oxygen.The patient is placed in the face-downwards

position as soon as anaesthesia is satisfactorilyestablished. The side of the chest which is to beoperated upon should be tilted slightly upwards.A long postero-lateral incision is made round thevertebral border of the scapula extending from thespine to a position situated well anteriorly. Thesurgeon, who has full cognisance of the site of thedisease, should then remove the rib appropriate tothe lobe or segment to be resected. Resection ofthe fifth rib ensures accessibility to the entirepleural space. It is difficult, however, to removean upper lobe after a seventh rib resection.The pleural cavity should then be entered and

any adhesions attaching the lung to the chest wallshould be divided. Adhesions, which are usuallypresent, are in many cases dense and vascular, andit is advisable to clamp them, divide them and thenseal them with an electro-cautery.

Dense Pleuro-Pulmonary AdhesionsThe lung may be firmly and inseparably attached

to the parietal pleura. The attachment generallyoccurs over old cavity areas and there is always therisk of tearing into the lung during any attempt atseparation from the pleural lining. If this ac-cident of opening into such cavitated areas with itsattendant contamination of the pleural space oc-curs, it is advisable to carefully wash out the pleuralcavity with saline when the resection is completed,in an attempt to minimize the danger of empyemaformation.An extrapleural separation of the lung from the

chest, wall over these firmly-adherent sites willavoid' this hazard, leaving the residual portion ofthe lung with an attached cap of parietal pleura.The bare area left by the removal of the parietalpleura may bleed a little, but this bleeding iseasily controlled by the application of hot swabs

maintained for some time in the requisite position.If, however, there is a slow oozing of blood fromthe raw surface, the blood loss should be replacedvia the intravenous drip apparatus.The operation of lobectomy involves the ex-

posure of the pulmonary hilum and the opening ofthe interlobar fissures. This procedure may be-come very difficult if the entire lung is covered by adense membrane, which juakes it appear to be asingle sheet of tissue undifferentiated into lobes.In such a case the mediastinal surface of the lungshould be exposed. This exposure will normallyallow of a demonstration of the interlobar fissuresand lobar differentiation.

Types of ResectionThe operations of pneumonectomy, lobectomy

and segmental resection of a lobe are the methodsemployed. As the operations are identical to thoseperformed for bronchiectasis, a general descriptionwill not be given in this paper and only specialfeatures of the operative technique will be dis-cussed.

Determination of the Extent of the DiseaseAs soon as the lung has been freed from all

attachments to the thoracic wall, the surgeonshould determine the extent of the disease. Radio-graphy may have indicated the presence of thedisease in a particular lobe, but actual palpationand inspection may reveal a far greater degree ofpulmonary involvement.When the extent of the disease has been deter-

mined the resection of the affected segment, lobeor lung can be performed according to the methodsof resection employed in the operative therapy ofbronchiectasis.

Repair of the BronchusMany different means of bronchial repair have

been described, but the method of choice is thatin which the minimum number of sutures is em-ployed. Care should be taken to avoid devitalizingthe stump of the bronchus by the use of clamps, asthis predisposes to fistula formation. The dividedbronchus should be treated with carbolic acid andalcohol in the manner used for the treatment of theappendix stump. This aids in the sterilization ofthe end of the stump, and destroys the mucousmembrane at that site, leading to rapid healingwith the formation of a satisfactory cul-de-sac.The first step in the repair of the bronchus-is to

fold the bronchus on itself and to insert two setsof mattress sutures. These sutures should be of anon-absorbable material, such as nylon thread, andthey should interloclk and be firmly tied. When thefirst suture has been inserted the anaesthetistshould be instructed to test the air tightness by

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increasing the pressure of the arfaesthetic gases.If an air-tight closure has been obtained the secondsuture should be inserted and equally firmly tied.

After pneumonectomy the bronchial stumpshould be short enough to allow of its retractioninto the mediastinum, where it can be adequatelyprotected by the aorta or the azygos vein.A small amount of a powder mixture of peni-

cillin, streptomycin and sulphanilamide should besprinkled on the stump prior to the repair of themediastinal pleura. After lobectomy the bronchialstump should first be dusted with antibioticpowder and then covered either by means of apleural flap or by the overstitching of the adjacenttissues.

Phrenic ParalysisPhrenic paralysis has been undertaken by many

surgeons in order to reduce the size of the residualspace after resections and to delay the full ex-pansion of the remaining lung tissue. In myopinion it is a thoroughly unsound procedure, fortwo reasons. First, the paralysis of the dia-phragm on one side will interfere with the coughmechanism: A patient who has had a resectionmust be encouraged to cough up the secretionswhich have collected, especially from the sidewhich has been operated upon. This becomesextremely difficult when the phrenic nerve hasbeen crushed.Even more important, however, is the fact that

phrenic paralysis causes paradoxical movement ofthe halves of the diaphragm. There is a rise inintrapleural pressure on the unaffected side duringcoughing and a corresponding fall in pressure onthe side which has been surgically treated. Theforce of the pressure will thus be borne by the re-paired bronchial stump with the grave risk of theformation of a bronchial fistula. The force of acough is directed against the glottis when bothsides of the diaphragm are active.The complication of bronchial fistula has not

been encountered in this series of cases.

Drainage of the Pleural CavityThe pleural cavity should be carefully washed

out several times with a saline mixture before theoperation incision is repaired. During this pro-cedure the lungs should be distended to preventany aspiration or leak into the bronchial system.This will demonstrate the air tightness of the re-paired bronchus.An intercostal drain leading into an underwater

drainage bottle should be inserted just above thediaphragm in a postero-lateral position. The in-troduction of a Foley catheter, which preventsinfection gaining entry via the tube, avoids thenecessity of transfixing the tube by means of a

stitch or safety pin. The balloon-like portion ofthe catheter is filled with a penicillin solution whichis allowed to run out before the catheter is re-moved.The catheter is generally withdrawn 48 hours

after operation. If, however, a portable X-rayexamination of the chest reveals a large residualeffusion which is still draining, the catheter mustbe retained in position for a longer period.

Post-Operative BronchoscopyThe manipulation during resection often forces

secretions into the bronchi from the lungs. Thesesecretions may lead to considerable respiratoryembarrassment, as the patient cannot expel themucus beyond the glottis. This is particularlyapparent after phrenic paralysis, which depressesthe cough reflex.A post-operative bronchoscopy, which will

establish the condition existing in the bronchi,should be regarded as a routine measure after re-section. There is no greater risk attached to apost-operative bronchoscopy than to a broncho-scopy performed on a properly anaesthetizedpatient during the process of investigation. Thewarning should be given, however, that the passageof a bronchoscope in an almost conscious un-anaesthetized patient may well lead to severe shockand death.A bronchoscopy may become necessary a day or

so after operation as the presence of unexpec-torated thick, tenacious sputum may cause severedistress. The bronchoscopy, which is performedon the patient under local anaesthesia in his bed inthe ward, gives instant relief.

Treatment of the Residual SpaceFor many years surgeons have been concerned

with the fate of the residual space. This problemis of greater importance following on a pneumo-nectomy as, after lobectomy, the remaining lobeor lobes expand and aid in the obliteration of thespace. Two important points should be con-sidered:

i. Overexpansion emphysema. If the unaffectedlung expands to such a degree that it encroaches onthe operated side, overexpansion emphysema de-velops. The patient becomes intensely dyspnoeicand manifests the complete picture of chronicbronchitis and emphysema. This complication,which may occur after pneumonectomy, carrieswith it a grave prognosis. 0

2. Exacerbation of quiescent tuberculous disease.This complication may be seen after a lobectomywhere a reactivation of quiescent foci may resultfrom the expansion of the remaining lung tissue.The actual effect of the emphysema which occursin the remaining lung tissue is usually negligible.

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Many devices have been employed in attempts toprevent the onset of overexpansion emphysema.Plastic moulds, shaped like a lung, have been in-serted into the pleural cavity. Leucite balls andolive oil mixtures have been used to keep themediastinum in its central position.We have found that the most efficacious method

is to maintain the pleural space with air in exactlythe way used in pneumothorax threatment. Onemonth after the pneumonectomy operation about25 cc. of a half-saturated solution of urea is placedin the pleural space. This causes a tissue reactionwith the formation of a firm, fibrous tissue layerover the entire area. Refills to maintain the pneu-mothorax may be given every six or eight weeks.By this process of maintaining a small pneumo-

thorax the mediastinum remains in a fairly centralposition and shows very little tendency to be dis-advantageously displaced. The residual lobe isslowly allowed to expand over a period of a yearor more.These methods of treatment have proved to be

very effective. In a remarkably small number ofcases after pneumonectomy the pneumothorax hasabsorbed very quickly and the sound lung hasshown early signs of encroaching on to theoperated side. An upper thoracoplasty has beenperformed, leaving the first rib intact. This hasavoided the dangers of overdistension emphysema.Many clinics have recommended routine post-

pneumonectomy thoracoplasties, and the thoraco-plasty may even be commenced at the time of thepneumonectomy operation. The use of thoraco-plasties as a routine procedure has not been con-sidered necessary in the cases under review.

Complications of Pulmonary ResectionThe possible complications of resection treat-

ment may be attributable to the actual operationor to the disease process itself.

HaemorrhageConsiderable blood loss may .attend the com-

bined operation of pneumonectomy and pleurec-tomy. The stripping of the thickened pleuralmembrane from the thoracic wall exposesnumerous bleeding surfaces. Adequate supplies ofblood should be available during the operation.As a rough guide one may estimate the amount ofblood lost as being equal to double the quantity ofblood sucked up by the suction apparatus. Itfollows then that this amount should be replacedduring the operation.

It is important to remember that the blood lossmay continue after the completion of the operation,and a blood transfusion should be given to replacethe quantity which has drained into the drainagebottle.

In my opinion P.A.S. treatment should be dis-continued about I4 days prior to operation.During this period the patient should receive dailyinjections of vitamin K. The continued ad-ministration of P.A.S., which is supposed to delaythe clotting time, may lead to serious post-operative haemorrhage.

Operative ShockA large degree of shock is not often encountered

during a straightforward lobectomy operation, butprofound shock may be seen where pleuralstripping has been done. If the lung is denselyadherent to the chest wall and a pneumonectomyis to be performed, the stripping should be carriedout while the anaesthetist gives intravenous pro-caine hydrochloride as a drip injection. Fbr thispurpose io cc. of i per cent. procaine should beadded to ioo cc. of normal saline solution.

Shock is not likely to occur after the pleuralstripping and the dissection of the hilum have beencompleted.

Infection of the Pleural CavityInfection of the pleural cavity may be due to

pyogenic organisms or to tubercle bacilli. Thepleural cavity may be contaminated at the time ofoperation by accidental entry into a tuberculouscavity. Careful and liberal washing of the pleuralcavity with saline solution should effectively dealwith all contamination and ensure primary healing.

Tuberculous infection of the pleural cavity may,however, only occur several days after the opera-tion. It is probably more correct to state that theinfection is recognized at that stage as the con-tamination probably had occurred at the time ofoperation.

In many cases, infection by tubercle bacilli wasonly seen after a difficult resection where the lungwas firmly attached to the chest wall and pieces ofpulmonary tissue had probably been left in theirattachment to the thoracic cage.

Tuberculous empyemata were not seen afterstraightforward pulmonary resections and the lowincidence of this complication has been attributedto the careful repair of the bronchial stump.

Analysis of the post-operative results reveals thefact that there is more likelihood of a tuberculousempyema developing after a segmental resectionfor infiltrated and cavitated areas. As an exampleof this I may cite a case in which the apex of thelower lobe was involved in a cavity of the upperlobe. A resection of the upper lobe and the apexof the lower lobe was performed and was followedin ten days by a tuberculous empyema. I considerthat the operation of segmental resection should bereserved for cases of tuberculomata and very local-,ized circumscribed cavities. It is not wise to resect

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a segment when infiltration is present, as the planeof division may penetrate through macroscopicallyinvisible tuberculous tissue.

Bronchial FistulaSigns of bronchopleural and bronchocutaneous

fistulae may present on the seventh to the tenthday after operation. Generally the patient coughsup the contents of the pleural cavity which,initially, consist of blood-stained material.This is a rare complication and has only once

been seen in a series of over 200 lobectomies andpneumonectomies performed for diverse con-ditions. It may be prevented by the carefulclosure of the bronchus and by the application of apleural graft over the stump.

Rapid healing has been obtained, by the closureof the bronchus by infolding and the use of aminimum number -of sutures. Usually twomattress sutures with nylon thread are sufficient togive the airtight closure of the bronchus, which isreinforced by the application of a pleural flap overthe repaired stump. The patient should bewarned that he may cough up stitches manymonths after the operation, as they are non-absorbable, and the sudden appearance of a smallstitch and a trace of blood-stained sputum may bemost alarming.

If a bronchial fistula develops, immediateadequate pleural drainage through the chest wallmust be provided to prevent the aspiration ofblood and serum into the pulmonary system. Theremaining lung tissue has usually become com-pressed and covered with a thick pyogenic mem-brane.' The' immediate drainage of the pleuralcavity encourages the expansion of the remaininglobes, which obliterate the pleural space. In thepast the use of the lung tourniquet was invariablyfollowed by fistula formation on about the tenthday after operation.

Spread of the Tuberculous DiseaseSpread of the disease is naturally the most

serious complication of the surgical treatment oftuberculosis. I have not been able to accept thetheory of the contralateral spread of tuberculosisvia the bronchi. This view states that the manipula-tion of the lung during operation favours the in-halation of infected material into the unaffectedside. This cause of contralateral spread shouldoperate similarly while the patient is in deepsleep.

Contralateral spread is not frequently seen.Even when copious quantities of infected sputumissue from the upper lobe the lower lobe of thesame side is seldom affected. In my opinion thecontralateral spread is probably a result of in-fected emboli containing tubercle bacilli being ex-

pelled into the blood stream and reaching theopposite lung via the pulmonary artery. The lungparenchyma acts as a filter to the bacilli and thisprevents the onset of generalized infection ormiliary tuberculosis.There is also the question of exacerbation of

quiescent or arrested disease. Many cases mayshow radiographic evidence of disease in the so-called' sound side ' of the chest. Unless pathologyremains unchanged for three months there isrelatively little use in performing a resection on themore seriously affected side. There is always thepossibility of an exacerbation of this quiescentdisease, but it has been' my experience that anadequate course of streptomycin and P.A.S. beforeand after operation considerably reduces thedanger of this unfortunate result.

It is important to remember that no signs oftuberculosis may be seen on the sound side byordinary radiological methods. Suspicious nodulesmay become apparent when softer radiographs aretaken and it can be assumed in some cases, wherepost-operative spread is suspected, that thepathology is really due to a reactivation of thesenodules. It is always a good plan, therefore, tosupplement ordinary radiography of the chest witha set of ' softer' films before a resection is per-formed.

Atelectasis of the Remaining Lobes after LobectomyMany surgeons in the past have deliberately

caused adhesions before resecting a lobe forbronchiectasis, as they believed that these ad-hesions would prevent collapse or atelectasis of theremaining lobes of the lung. Similarly, manysurgeons today, in treating tuberculosis by lobec-tomy, feel more satisfied if the remaining lobes areattached to the chest wall by the type of denseadhesion that one sees after prolonged pneumo-thorax therapy. Actually these residual adhesionsdo not prevent collapse, but prevent re-expansionof the remaining lobes. It is my practice to sepa-rate the remaining normal lobes from the parietesand to divide all the restraining adhesions. Theanaesthestist is then requested to distend theselobes in order to be assured of their full expansion.The rest provided to the diseased lung by thepneumothorax treatment may thus become asource of embarrassment to the lung by virtue ofthe subsequent fixation and immobilization.

Residual Effusion in the Pleural SpaceThere is a grave danger of a residual effusion

remaining after the operations of lobectomy andpneumonectomy becoming infected. It has beenstated that if the bronchial stump is adequatelyrepaired fistula formation is not likely, and con-sequently infection does not supervene. Large

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May i95 PHILLIPS: The Treatment of Pulmonary Tuberculosis by Surgical Resection

effusions, however, may rupture into the bronchialsystem if severe strain results from a bout ofcoughing. It is therefore important to ascertainthat a minimal residual effusion exists. The drain-age tube should allow all effusions to escape duringthe first 48 hours after operation. Subsequent tothis regular 48 hourly radiographic examinationswill manifest the presence of accumulating secre-tions. If the effusion is large enough to compressthe remaining lobe or lobes, or to displace themediastinum, the chest should be aspirated. Thisaspiration may involve the removal of air as wellas effusion. It is not necessary to try and emptythe pleural cavity as attempts to drain it completelymay result in damage to the remaining pulmonarylobes from the point of the aspirating needle.The incidence of these large troublesome

effusions has not been high and aspirations haveonly been necessary in less than io per cent. ofcases. A mixture of one million units of peni-cillin and I gm. of streptomycin should be in-jected into the pleural space after aspiration. I,personally, believe that a small effusion serves auseful purpose, as it controls rapid overexpansionof the remaining lobes after a lobectomy. Thepresence of the effusion and air also helps tomaintain the mediastinum in a central positionafter a pneumonectomy has been performed.

Post-Operative EmphysemaThe problem of post-operative emphysema,

which has been previously discussed, is closelybound up with the problem of the residual pleuraleffusion. While overdistension emphysema is notof significance after a lobectomy it is extremelyimportant after a pneumonectomy, particularlyafter a pneumonectomy on the right side in whichthe pleural space is much larger than on the left.The prevention of overdistension emphysema mustbe stressed, as it may convert the patient into acomplete respiratory cripple.The mediastinum is movable for the first few

weeks after pneumonectomy, and if a high negativepleural pressure exists on the side of the resectionthe remaining lung will over expand until iteventually displaces the mediastinum into thepleural space. Many surgeons prevent this oc-currence by proceeding with an early post-pneumonectomy thoracoplasty, but this is notnecessary in all cases.The maintenance of a pneumothorax on the re-

sected side until the pleural reaction is sufficient tocause mediastinal fixation has been described.The presence of a small effusion in the pleuralspace aids in this process, as it leads to more rapidthickening of the pleural lining.When the mediastinal pleura is very thick and

rigid gross displacement of the mediastinum

cannot occur. The small amount of displacementwhich results is no greater than that seen followingthoracoplasty. The indications for a thoraco-plasty to prevent post-pneumonectomy emphysemaare quite straightforward. If rapid displacement ofthe mediastinum takes place, in spite of thepneumothorax refills, a thoracoplasty should beperformed about six to eight weeks after thepneumonectomy.

Post-Operative PhysiotherapyPost-operative physiotherapy should be com-

menced 24 hours after the operation and if thepatient's condition permits he should discard thesupine position as soon as possible. On the secondpost-operative day he should sit up with his feetdangling over the side of the bed, and on the thirdday he should be helped out of bed.The remedial exercises aided by an expert

physiotherapist are of paramount importance inensuring good posture and the maximum use ofthe remaining pulmonary tissue.

ConvalescenceIt is my custom to recommend a period of six

months controlled convalescence in a sanatorium.It is not always possible for the patient to arrangefor this extended period of rehabilitation, eventhough it is offset by the fact that the actualduration of hospitalization is comparatively short.During this time careful re-education by meansof graduated exercises must be carried out andfrequent radiographic and sputum examinationsshould be performed.We are often forced to face the problem that

patients treated by resection methods are notwilling to go to sanatoria for fear of ' contractingtuberculosis again.' This attitude has been seenin practically every case discharged from thethoracic surgical unit to a sanatorium. In anattempt to ease this unfortunate quandary we havetried to separate all the cases who regard them-selves as free of infection, though this procedure isnaturally not always possible.

The Follow-upA routine monthly general examination and

sputum test should be undertaken after the patienthas left the sanatorium. A new full-sized X-rayfilm of the chest should be reviewed every twomonths. We make a point of stressing to thepatients the fact that they may still have latentpulmonary tuberculosis, as this seems to encouragethem to attend for regular examinations.

ResultsA series of 50 cases of pulmonary tuberculosis

treated by resection is reviewed (Table I). There

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232 POSTGRADUATE MEDICAL JOURNAL May Is95

TABLE I

Contra-Lateral Disease Broncho-Operation Cases Deaths - Pleural Empyema

Present Spread Reactivity Fistula

Lobectomy 38 0 8 0 0 0 0

Lobe + Segment Resection 4 I 2 0 I 0 *I

Pneumonectomy 8 0 0 0 0 2

Totals 50 I IO 0 I 3

These results extend over a period of six to twelve months after operation.

was one death occurring 24 hours after operation.The patient complained of a sudden pain in thechest, sat up and died within a few seconds. Therewas no evidence of a pulmonary embolus andunfortunately an autopsy was refused.

ConclusionsResection treatment, which closely approxi-

mates a cure for the disease, is favourably re-garded today by thoracic surgeons as it offers axneans of actual removal of permanently damagedlung tissue.A short period only of hospitalization is neces-

sary, which is of great importance in these days ofbed shortage.The patient welcomes this form of treatment

which, to him, shows a reasonable line of approach,and psychologically he benefits as he no longerconsiders himself ' a tuberculous outcast.;

This paper deals with the indications for re-section in pulmonary tuberculosis, the techniqueof resection and the complications that mayarise.The post-operative physiotherapy, the con-

valescence and the follow-up of the patient arebrieflv outlined.

ANNOTATION

Glucose Tolerance TestsA reduction of the body's power to dispose of

ingested carbohydrate results in its failure to main-tain the blood sugar concentration constantlywithin normal limits. In order to reveal such adeficiency, sugar metabolism as a whole may -bestrained by the imposition of a glucose load uponit, abnormally high blood sugar levels afterwardsshowing that glucose tolerance is reduced. Glucosetolerance tests are designed with this object, andin the past 30 to 40 years the methods and results,in normal and abnormal stateq, have been standard-ized by various investigators.The most commonly employed test involves the

estimation of the blood sugar at half-hourly, andthe urinary sugar at hourly intervals for two hoursafter the administration of 5o gm. glucose by

mouth. Criteria of normality have been establishedfor this test by its performance upon series ofhealthy young adults. The blood sugar should bebelow I20 mg. per ioo ml. with the subject fasting,and findings above this level indicate reducedtolerance (Mosenthal, I947; Moyer and Womack,1950). It is agreed by most that the venous bloodsugar two hours after taking the glucose should notnormally exceed I2o m.g per ioo ml. (Hale-Whiteand Payne, I926; Langner and Dewers, 1942).Many consider that this particular blood sugarlevel is the only accurate criterion of sugar toler-ance. The blood sugar level attained at the inter-mediate times during the test is of debatablesignificance. Joslin (1946) considered that non-fasting sugar concentrations above 170 mg. per iooml. in venous blood and 200 mg. per ioo ml. incapillary blood indicated diabetes mellitus, andhence reduced tolerance if accompanied by glyco-stiria. Spence (1920), MacLean and de Wesselow

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