Wednesday Morning, March 30, 1949

9:00 A.M. Scientific Session.

12. The Surgical Management of Chronic "Spontaneous" Pneumothorax.

Lyman A. Brewer, III, M.D., Frank S. Dolley, M.D. and

(by invitation) Byron H. Evans, M.D., Los Angeles, Calif.

A series of cases of chronic and recurring "spontaneous" pneumothorax is presented. "Symptomatic" pneumothorax occurring with well established pulmonary disease secondary to trauma, pulmonary abscess, infarct, tuberculosis and lung tumors has been excluded. Although there is a great controversy concerning the etiology of "spontaneous" pneumothorax, from the practical point of view we recognize three main conditions as causing the vast majority of these cases: 1) Congenital cysts, occurring most often in infants and children; 2) Pulmonary vesicles, secondary to localized subpleural pulmonary and bronchiolar scars occurring in young adults; and 3) Blebs or bullae of emphysema found in middle aged or older persons suffering from a more generalized form of pulmonary emphysema. Most cases of acute "spontaneous" pneumothorax can be successfully treated by conservative methods, which include bedrest, oxygen, and the adjustment of the intrapleural pressures to allow for the scaling off of the pulmonary aperture and the gradual expansion of the lung.

Chronic "spontaneous" pneumothorax presents a more difficult therapeutic problem. Surgical methods are indicated because conservative measures have failed. With surgery maximum pulmonary function is restored and chronic invalidism prevented.

The causes of the persistence of the pneumothorax are sometimes difficult to demonstrate. Most often, however, the etiologic factor is one of three main conditions: 1) Intrapleural adhesions, which exert a "guy wire" effect on the lung, holding it on a tension so that the lung cannot collapse sufficiently to allow the pulmonary opening to close; 2) Fibrosis about the opening in the lung or a congenital lesion lined by bronchial epithelium; 3) The formation of a pleural membrane as the result of the organization of fibrin deposits secondary to a pleural effusion. Because of the nature of the pathological processes, we believe that the introduction of irritating substances into the pleural cavity to produce a violent pleuritis is contraindicated. The surgical measures we have employed include: 1) Closed catheter pleural drainage; 2) Phrenic paralysis; 3) Thora-coscopy with internal pneumonolysis; and 4) Open thoracotomy. Open thoracotomy permits the most complete and definitive attack to the problem, for at this operation four essential techniques may be employed: 1) Complete pneumonolysis; 2) Surgical closure of the pulmonary opening; 3) Resection of pulmonary cyst or bleb regardless of the type; 4) Decortication of the collapsed lung. This subject has received little attention in the medical literature. The authors wished to present their experience with the surgical management of 15 cases. The indications and results of the various surgical techniques are discussed and evaluated.

13. Segmental Resection in Pulmonary Diseases.

J. Maxwell Chamberlain, M.D. and (by invitation)

Thomas C. Ryan, Commander, U.S.N., New York, N.Y.

One hundred segmental resections were done for tuberculous (25%) and non-tuberculous (75%) pulmonary lesions. The standard technique first suggested by Churchill was used in the majority of cases. The bronchus serving the diseased segment is defined and divided. Gentle traction on the bronchus soon discloses the companion vessels and the artery is ligated first. Only the tributaries to the vein are ligated, however, since it has been pointed out that the veins serve adjacent segments.

The indications for segmental resection in bronchiectasis are well known, but segmental resection in acute putrid lung abscess is usually contra-indicated. However, after chemo-therapy or surgical drainage of a lung abscess, a state of indolent chronicity may be reached and in such cases segmental resection becomes a sound surgical solution. The indications for segmental resection in tuberculosis are not well established, but it would seem that the small, discrete, isolated focus such as a tuberculoma or a small thick walled inspissated cavity are the two types of lesion most vulnerable to resection of a segment.

In comparison with the removal of a lobe the operating time and complications are moderately increased. Further, the postoperative care is more complicated and demands great vigilance. The results, however, seem to justify the continued use of this procedure. However, when only one segment of a lobe remains and this segment is a small one, a lobectomy may be the procedure of choice.

The various methods of segmental resection will be discussed and typical cases with broncho-spirometric studies will be presented.

14. Resection of Pulmonary Segments-Details of Technic and Recent Results.

Richard H. Overholt, M.D., Francis M. Woods, M.D.

and (by invitation) Beatty H. Ramsay, M.D.,

Brookline, Mass.

The operative procedure of segmental resection of the lungs has now matured. Nearly all the technical difficulties have yielded to improvements in technic until now it can be demonstrated that empyema, bronchopleural fistula, and difficulty with reexpansion of the remaining lung are uncommon and unexpected complications. It is our purpose to record the difficulties that have been encountered and to show how each may be best avoided. Detailed technical steps of the operation will be illustrated. Brief reference will be made to the use of segmental resection in pulmonary malignancy and tuberculosis. Finally, a report will be given on the postoperative course in all the segmental resections carried out during the past six months during which time technical maneuvers and management have remained unchanged.

15. Broncholithiasis.

Herbert W. Schmidt, M.D. (by invitation)

O. Theron Clagett, M.D., and John R. McDonald, M.D.,

Mayo Clinic, Rochester, Minn.

The subject of broncholithiasis has been of interest to the medical profession for centuries. It has been said that the subject interested Aristotle some three hundred years B.C. In spite of this fact, we could find only seventy-eight cases reported in the English medical literature up to 1948.

We should like to report forty-two cases of broncholithiasis in our experience. In fourteen of these cases, the broncholith was removed at the time of bronchoscopy. In three, it was impossible to remove the stone at the time of endoscopic examination but the involved bronchus was dilated and the stone was coughed up immediately following the examination. Ten patients had pulmonary resections for indeterminate lesions which were proved to be due to broncholiths. The rest of the patients in this series had the history of having coughed up single or multiple stones. The clinical, bronchoscopic, pathologic and surgical aspects of broncholithiasis are discussed.

Broncholiths will be diagnosed with increasing frequency at the time of exploratory thoracotomy performed because of indeterminate pulmonary lesions. In this group it will usually be necessary to carry out a resection of a portion of the lung because primary bronchi-ogenic carcinoma in most instances cannot be excluded. Because of the pathology involved, we believe that as small an amount of lung tissue as possible should be resected at the time of surgery.

16. The Results of Surgery in Bronchiectasis.

Adrian Lambert, M.D., New York, N. Y.

The series representing an analysis of 106 consecutive operations on 103 patients for bronchiectasis, with and without acute sup-purative disease, and involving one or two lobes and an entire lung, is offered from the Chest Division of Bellevue Hospital during the years 1939 to 1945. Cases in which tuberculosis was demonstrated in the specimen removed have been omitted from this series. Similarly, cases in which the primary disease process was a lung abscess have not been included. The mortality in bronchiectasis with and without suppuration in one or two lobes and involving an entire lung is analyzed. The postoperative complications have been related to the operative technic and to the existing pathology in the specimen removed and the incidence of sputum related to the mortality in the four groups. The results include a follow-up of seventy-eight of the ninety-one survivals that were followed over an average period of four years. These have been classified according to the original pathology at the time of operation, according to associated sinus disease and bronchiectasis and according to postoperative residual stumps and the development of tuberculosis.

17. The Surgical Treatment of Bilateral Bronchiectasis.

Frederick G. Kergin, M.D., Toronto, Canada

Fifty-eight patients have been treated surgically for bilateral bronchiectasis at the Toronto General Hospital and Hospital for Sick Children, Toronto. Of these, twenty-seven have had unilateral operations and thirty-one have had staged bilateral resections.

This group of patients has been subjected to ninety-four excision operations with four deaths, all following the second side of a bilateral resection. By attention to certain technical details, which are described, it has been possible to reduce the hazards of treatment. The last eighteen consecutive bilateral resections have been completed without mortality.

The results of treatment in relation to relief of symptoms and effect on exercise tolerance are discussed. Eighty-three percent of the patients who have had bilateral resection are symptom free and the remainder improved.

In this series partial lower lobectomy with preservation of the superior segment was done thirteen times. The results of this procedure are described.