Saturday Morning, March 28, 1953

9:00 A.M. Scientific Session.

13. The Present Chaos Which Exits Regarding Pulmonary Resection.

E. J. O'Brien and Paul V. O'Rourke, Detroit, Mich.

The paper deals with the present confusion existing in resection for pulmonary tuberculosis. It describes Doctor Medlar's excellent contribution but questions all the conclusions that many have drawn from it. Most pathological reports of so-called fibrocaseous lesions found in residues fail to indicate how much of these were mostly fibrotic, and how much caseation existed. Seldom are tubercle bacilli found in these lesions reported viable. Some clinics are resecting everything. We are led to believe that thoracoplasties and other collapse measures in these places are practically obsolete.

Suggestions of present indications for resection shall be attempted. A discussion of complications following unnecessary resection shall be made. Some evaluation of phrenics, pneumothorax, pneumoperitoneum and thoracoplasty will be included. The paper obviously is controversial, but the hope is that discussion will somewhat clear the present chaotic approach to the problem. The difficulties following long term treatment with antibiotics, etc., together with their relationship to resection will be covered.

At present we are in many instances just guessing as to which lesion to resect. It is the hope of the authors that we may all get together on definite indications with our present knowledge of resection, and let the future decide by the number of relapses of small residual lesions after long treatment without resection. We can never know what would have happened to them if we resected all of them indiscriminately. Past experience of reactivation without prolonged antibiotics are of absolutely no value, and we have not yet had enough time to evaluate the present treatment.

14. The Use of Isoniazid as a Prophylactic Anti-Bacterial Agent in Pulmonary Resection for Tuberculosis. A Preliminary Report.

Max E. Childress (by invitation), Mildred E. Thoren (by invitation)

and Albert C. Daniels (by invitation), Weimar, Calif.

It is established that prophylactic antimicrobial therapy for pulmonary resection in tuberculosis is advantageous. Frequently such an advantage is lost, due to previous chemotherapy with resultant resistance of the tubercle bacillus to the chemotherapeutic agent. The desirability of having one or more short acting anti-tuberculosis drugs for pulmonary resection is obvious. Patients whose organisms are streptomycin-resistant may have the benefit of surgery under the protection of the short acting agent. Also, patients who have had no previous antimicrobial therapy may be placed on streptomycin and paraaminosalicylic acid without fear of developing resistant strains of bacteria to jeopardize a possible later operative procedure. This latter statement implies proper timing in the use of the short acting prophylactic anti-tuberculosis drug.

The present study, which is underway, attempts to answer the following question: "Does isoniazid afford adequate anti-bacterial protection during the operative period and for a postoperative follow-up of two months?"

Approximately 20 patients will be included in this investigation. The majority will have received streptomycin and PAS at one time or another during their illness. Some of them will have developed from a partial to a complete resistance to streptomycin.

All patients in the series are being carried solely on isoniazid during operation and for a postoperative period of two months. The isoniazid is started from twenty-four to forty-eight hours prior to surgery, unless the patient has a copious amount of tracheobronchial secretions. Then the medication is started two weeks prior to surgery in an effort to reduce the volume of these secretions. Two hundred milligrams of isoniazid are given daily by the oral route, except for the first few postoperative days when it is given intramuscularly.

The extent and type of disease will be considered in attempting to answer the question stated above. The final results will be tabulated in terms of postoperative complications due to tuberculosis.

15. The Influence of Long Term Chemothrapy on the Surgery of Pulmonary Tuberculosis.

John D. Steele, B. G. Narodick (by invitation) and A. V. Cadden

(by invitation), Milwaukee, Wise.

The use of long term chemotherapy in the treatment of pulmonary tuberculosis has presented us with entirely new surgical problems. The indications for pulmonary resection and collapse therapy in patients receiving such long term chemotherapy are not clearly defined at the present time.

Our present program of surgical therapy in the treatment of pulmonary tuberculosis was begun shortly after the report of Ryan, Medlar and Welles before this Association in April, 1951. The majority of our patients in this series have had small pulmonary resections after maximum recession of their lesions on chemotherapy. We have considered that the most important question in regard to the lesions so removed has been the viability of tubercle bacilli contained in them.

As of October 15, 1952, 101 resections had been performed on 90 patients having original courses of chemotherapy. The lesions removed at 14 operations appeared insignificant and were not cultured. Of the lesions removed at the time of the remaining 87 thoracotomies, 49 were positive for tubercle bacilli on smear or tissue section and 10 of these were positive on culture. Four of these positive cultures were obtained from lesions of patients who had received from 12 to 18 months of chemotherapy (original courses); 3 were from patients having 8 to 12 months. Breakdown of the positive cultures according to the regimen of SM therapy used showed no significant differences. Of 18 resected specimens from 14 additional patients receiving retreatment courses (interrupted) of chemotherapy, 4 were positive on culture. A few patients had resections after 8 months of INH therapy. The bacteriology will be reported.

The results of cultures from 40 additional operations may be reported by the end of March, 1953. By March, approximately 35 patients will have been studied for at least a year following resection. To date there have been 3 patients who have had bacteriologic relapses.

The rather high incidence of operative complications in our series of small resections will be reported. These have required secondary thoracotomies in approximately 10 percent of our patients. Few complications have been serious and there has been no mortality in this series.

In our summary, our current indications for resection and thoracoplasty following long term chemotherapy will be given.

16. Segmental Resection of Pulmonary Tuberculosis: An Analysis of 300 Cases Folio wed-from One to-Five Years.

J. Maxwell Chamberlain, Robert Klopstock and Charles F. Daniels

(by invitation), New York, N.Y.

In the surgical treatment of pulmonary tuberculosis we have performed 300 segniental resections upon patients who have been followed from one to five years. The morbidity and mortality rates for the entire series is reported and special emphasis is directed at the complications which are divided into two types: minor and major.

The results from a bacteriological viewpoint are extremely encouraging and the complications have decreased as our experience increased. The indications for the operation are presented and in the discussion the postoperative management is reviewed.

17. Electrolyte Studies in Pericardial Resection.

Walter B. Crandell, Andrew Yeomans (by invitation),

David Hoffman (by invitation) and George H. Stueck, Jr.

(by invitation), White River Junction, Vt.

Metabolic studies have been carried out on two cases of pericardial resection for constrictive pericarditis and a comparison is made between the two in regard to the immediate postoperative course which was benign in one and stormy in the other. An analysis of data obtained indicates that a regime of restriction of sodium intake can be carried so far as to be deleterious, and the following evidence is presented to support this view.

1) During the eight days of balance studies prior to operation, an accumulative deficit of nearly 1000 milliequivalents (23 gms.) of sodium occurred through withdrawal of pleural fluid and dietary limitations.

(2) Total urinary sodium excretion for the 72 hours before operation was only 25 milliequivalents (normal is 100 meq/ day).

(3) The blood pressure drop occurred while receiving blood and did not return to normal in spite of replacement of the estimated blood loss and with normal values for hematocrit, plasma volume, and blood volume.

(4) Serum sodium levels became abnormally low and remained so after clinical improvement.

(5) Hypotension and oliguria were overcome at about the time that the marked sodium deficit was corrected.

(6) The clinical features and laboratory changes resembled the peripheral vascular collapse produced by salt depletion in experimental animals.