Tuesday Morning, April 17, 1951

9:00 A.M. Scientific Session.

13. Thoracoplasty Combined With Resection for Pulmonary Tuberculosis.

William S. Conklin and Jerome T. Grismer (by invitation)

Portland, Oreg.

Pulmonary resection is considered indicated for some types of tuberculous pathology, particularly those which have failed or are likely to fail in their response to other types of treatment. Following pulmonary resection thoracoplasties have frequently been performed in order to: (1) Prevent overdistention of remaining portions of the lungs. (2) Prevent or control complications such as empyema and bronchopleural fistula. (3) Prevent excessive mediastinal displacement and cardiovascular embarrassment. (4) Control nonresected tuberculous lesions.

It appears that many radical resections (pneumonectomies) have been performed in recent years because middle and lower lobe lesions have been found at surgery when resection of only a diseased upper lobe had been planned preoperatively. We believe that only those lesions which are unlikely to respond to other types of management require resection and that as much functional lung tissue as possible should be conserved, even when tuberculous lesions, susceptible to other types of treatment, are grossly evident elsewhere in the lung. Conservation of lung tissue is especially important when there are contralateral tuberculous lesions of questionable stability or when vital capacity is limited.

When resection and thoracoplasty are performed at the same operation, rather than separately, there appear to be these definite advantages : (1) The combined operation seems to be as well tolerated as resection alone. (2) It eliminates one additional major operative procedure with its attendant risk and expense. (3) It provides the protection of thoracoplasty to a patient who might refuse to have two operations. (4) The combined procedure allows better exposure of the uppermost ribs through an incision which is shorter than that generally used for thoracoplasty alone. There is less damage to the muscles of the shoulder girdle and postoperative deformity (scoliosis) is minimized. (5) It permits earlier, more rapid obliteration of the pleural dead space, decreasing the hazards of bronchopleural fistula and empyema. (6) It conforms the size of the intrapleural space to that of the remaining lung segments before these have become over-distended and adherent. When thoracoplasty is not performed until weeks after resection adhesions limit the mobility of the lung and only the upper portion tends to be collapsed or relaxed by the thoracoplasty. (7) With an "elective" upper lobectomy concomitant thoracoplasty need not be as radical as primary thoracoplasty for control of the disease. Hence less deformity and functional impairment results. (8) Radical resection (pneumonectomy) may be avoided in certain cases, conserving bronchopulmonary segments that are relatively uninvolved. (9) By eliminating an additional operative procedure it decreases the load on the hospital's surgical facilities and increases the number of patients who may be treated surgically in a given period of time.

Our technic for the combined resection and thoracoplasty involves an intercostal incision and resection of graded segments of the first four or five ribs. The chest wall collapse is "molded" to conform to the conserved portions of the lung. When additional thoracoplasty seems indicated (e.g., following pneumonectomy) this is generally performed approximately two weeks following the original operation. The combined procedure is applicable and has been used when all or part of an upper lobe and of adjoining lung segments are resected. It is also used with pneumonectomy. It is not recommended when only a lower lobe is being resected. Obviously it is applicable in resection for nontuberculous as well as those for tuberculous pathology.

Approximately 30 cases will be reported in which the combined procedure has been utilized.

14. Results in 278 Patients Who Had Modern Type of Thoracoplasty for Tuberculosis.

William M. Lees, Stephen C. H. Yang (by invitation),

Michael Papoulakos (by invitation), Jan K. Bosch

(by invitation), John Alexander and Angel Larralde

(by invitation), Ann Arbor, Mich.

The lack of information concerning what happens to patients five years or more after thoracoplasty for pulmonary tuberculosis prompted us to conduct this study. Patients were not selected in any way except that they were all from the Michigan State Sanatorium at Howell, Michigan, and all had the same type of operation prior to December 1944, so that a minimum of five years had elapsed between the operation and the time of the study. All patients submitted to x-rays and sputum cultures were obtained before they were included in the study.

Two hundred and seventy-eight patients were so followed, five to fifteen years after their thoracoplasty, the majority performed for cavitary disease. Seventy-five patients or 26.9% were dead at the time of the study. Of the 203 patients remaining alive, 174 or 85.7% had negative sputa. If the total group of 278 is considered, 19 patients with negative sputa who died five or more years after thoracoplasty may be added to the negative group. Thus of 278 patients, 193 or 69.4% had negative sputa five or more years after operation. 157 patients or 77.3% of the living patients were working full or part time and considered themselves well. Eleven or 5.4% stated they were well but could not work. An analysis of the entire group, including the causes of death, is presented.

15. Simultaneous Decortication and Resection in Ineffective Pneumothorax.

Arnold O. Riley (by invitation) and Victor Kaunitz

(by invitation), Mount Morris, New York

The present literature includes numerous papers concerning decortication as a definitive therapy in tuberculosis involving primarily arrested or healed pulmonary disease. This paper presents, we think, a new concept in indications for decortication in pulmonary tuberculosis.

Our concept includes two basic divisions of cases of unexpanded lungs. First, we consider those arrested or healed cases in which there has been such extensive parenchymal involvement that reexpansion of involved areas is not desired, or such extensiye fibrosis of peel and parenchyma that decortication is technically difficult if not impossible. Second, we include those with positive sputa due to a varying extent of pulmonary disease in which pulmonary excision of involved segment or lobe is combined with decortication. In both of these groups a preliminary tailoring thoracoplasty is done to prevent overdistention and its attendant dangers, and to assure obliteration of pleural space. These indications are applied to simple noninfected unexpanded lungs as well as to tuberculous empyemata.

This paper includes a discussion of the incidents of pleural complications of pulmonary tuberculosis treated with pneumothorax and simple tuberculous effusions; older methods of treatment of these conditions; indications including those presently accepted plus the above concepts; preoperative evaluation, preparation, surgical technic, and postoperative care; case presentations (one case illustrating each indication) ; results of personal series (as of now, 14 cases); and summary.

16. Decortication Preceding Thoracoplasty for Eradication of Long Standing (Up to Six Years) Chronic Tuberculosis and Mixed Infection Empyema.

F. Douglas Ackman, Montreal, Canada

The unsatisfactory and crippling results of the Schede type of thoracoplasty for the long standing chronic empyema engendered the plan to decorticate first and, by so doing, eliminate or reduce extensive thoracoplasty.

Encouragement for this idea was derived from the observation that in empyema cases where massive lower lobe adhesions held the lower lobe out, ordinary limited thoracoplasty has been most successful in entirely eliminating the empyema.

Results in the few cases (10) have been encouragingly successful generally requiring only limited thoracoplasty and twice making the thoracoplasty unnecessary.

17. Simple Excision in the Treatment of Pulmonary Tuberculosis.

Bernard J. Ryan (by invitation), Edgar M. Medlar

(by invitation), Sunmount, N. Y.

and Edward S. Welles, Saranac Lake, N. Y.

A series of approximately 25 cases in which very small wedges or subsegments of pulmonary lobes have been removed is presented. In most instances the operation has been performed in conjunction with long term combined streptomycin and para-aminosalycylic acid therapy. Some of the patients showed marked clearing of their disease on long term antimicrobial therapy and a small persistent residual necrotic focus was resected. In others, foci which showed little change by x-ray during antimicrobial therapy were removed. All postoperative sputum cultures have been negative. There have been no deaths or tuberculous complications.

Extensive bacteriologic and pathologic data have been obtained in each case. The rationale for this form of surgical therapy is closely correlated with Medlar's concepts of the pathogenesis and pathology of pulmonary tuberculosis. Illustrative cases are presented.

18. Subscapular Paraffin Pack as a Supplement to Thoraco-plasty as a Collapse Procedure.

W. E. Adams, William M. Lees .and James M. Fritz

(by invitation), Chicago, Ill.

In the surgical treatment of pulmonary tuberculosis, thoracoplasty occupies an important position. When properly employed, successful control of the pulmonary lesion may be expected in a high percentage of cases. However, all too frequently an active process remains because of inadequate collapse, thus necessitating further surgical therapy.

During the past three and one-half years the usual thoracoplastic operation has been supplemented by a subscapular paraffin pack in collapse therapy for pulmonary tuberculosis. At first most procedures were carried out in two or three stages. Later, after further experience, a one-stage operation which entailed resection of five, six or seven ribs and paraffin pack has been done.

The principal advantage obtained by the addition of wax is a definitely better ultimate collapse of the diseased part. In addition, fewer stages are required and thus an economy is effected. This method also involves resection of shorter segments of the transverse processes, thus lessening the degree of postoperative scoliosis.

At present, complications and risk of operation are no greater than in thoracoplasty without the addition of paraffin.

Our experience has been with a series of 27 patients. One of the earlier individuals who had a two-stage operation, expired shortly after the second stage from a continuation of the disease which had been active bilaterally. There has been one superficial wound infection which subsequently healed. Extrusion of a portion of the paraffin occurred in one case due to the accumulation of fluid. The end results in this case, however, were satisfactory. Indications and contraindications as well as safeguards will be discussed.