Wednesday Afternoon, May 5,1954

2:00 P.M. Scientific Session: REGULAR PROGRAM.

37. The Viability of Tubercle Bacilli in Healed Tuberculous Lesions Following Long-Term Chemotherapy.

Gladys L. Hobby (by invitation), Oscar Auerbach, Tulita F. Lenert

(by invitation), Maurice J. Small (by invitation) and John V. Comer

(by invitation), East Orange, N. J.

This study was undertaken to determine the viability of tubercle bacilli in resected lesions from patients who had had long-term chemotherapy and who had been culture negative for periods of several months. Eighteen patients were studied. These fell into the following groups: (1) Nine patients who, we believe, met the criteria defined by D'Esopo et al. for "target point" lesions (8 had received more than 8 months of chemotherapy and 1 had received 4 months of chemotherapy) ; (II) two patients who met all of the criteria for "target point" lesions except that smears (but not cultures) were positive within a period of 1 to 2 months prior to resection; (III) two cases who met the criteria for "target point" lesions, based on roentgenographic evidence and duration of chemotherapy, but had one isolated positive culture 4 to 6 weeks prior to resection, after having been culture negative for a period of several months previously; (IV) three patients with negative cultures and patent cavities; and (V) two control patients.

In Group I (9 patients), positive culture occurred in 7; of 17 lesions examined, 11 were positive by culture. In Group II (2 patients), 4 of 5 lesions were culture positive. In Group III (2 patients), 2 lesions were negative by culture and by guinea pig inoculation. In Group IV (3 patients), all 8 lesions were positive for tubercle bacilli on culture. In Group V (2 control patients), 2 lesions were positive. From these data, it is apparent that viable tubercle bacilli were present in the majority of the lesions studied.

Comment will be made in the present report concerning the nature of these lesions, and concerning the microbiological technics utilized for cultivation of the organisms present in them.

38. Resection Surgery in Tuberculosis: Complications and After-History.

Richmond Douglass, James M. Judd (by invitation), E. B. Bosworth (by invitation)

and K. H. Chang (by invitation), Ithaca, N. Y.

A group of 508 patients who had received antimicrobial therapy were submitted to resection surgery for tuberculosis during the years 1948-53. Pneumonectomy was done in 39, lobectomy was the major procedure in 127, segmental resection in 215, and local excision in 209. Bilateral procedures were carried out on 74 patients.

The postoperative complications and morbidity for the entire group is reviewed. A distinction is drawn between "salvage" and "elective" cases and an attempt made to weigh the operative risks for the latter group in particular. The after-history of the 1948-52 patients is presented for both the "salvage" and "elective" groups by the Anniversary Method of Bosworth and Ailing. The "salvage" group consisted of 107 patients of whom 10 died, 9 in the postoperative period; while 5 deaths, all postoperative, occurred in the elective group of 401 patients.

A special subgroup of 141 patients in whom all palpable and X-ray demonstrable disease was removed has been designated for special study. The postoperative course is considered to be completely satisfactory in 96 per cent.

39. The Coordination of Surgery and Combined Chemotherapy in the Treatment of Pulmonary Tuberculosis.

Alfred M. Decker (by invitation), James W. Raleigh (by invitation)

and Edward S. Welles, Sunmount, N. Y.

Although 80% or more of drug sensitive cases of pulmonary tuberculosis convert their sputa during prolonged combined therapy, only 50-70% close all lesions. Classification as CLOSED NEGATIVE, OPEN NEGATIVE and OPEN POSITIVE seems convenient.

The worth of this categorization in evaluating surgical intervention during therapy is suggested by the following observations:

Sputum conversion approaches 100% in the absence of open lesions. Failure to convert or bacteriologic relapse during or after prolonged therapy is common if open lesions persist. Relapse is rare within 4 years following therapy in the CLOSED NEGATIVE group, resected or unresected.

Resected open lesions are significantly more often positive on culture than are closed lesions. In the OPEN groups, patients resected appear to save a definitely lower relapse rate than those unresected.

Therapeutic failures and tuberculous operative complications are much more infrequent in the CLOSED NEGATIVE and OPEN NEGATIVE groups than in the OPEN POSITIVE group. Failure to achieve persistent sputum conversion after 6-8 months of treatment permits emergence of resistant organisms in an increasing percentage. It is suggested every effort be made to close cavitary lesions in the first 6-8 months of combined therapy. If closure is achieved, the necessity for resection remains an open question. If closure is not achieved, prompt resection of residual open lesions appears to offer therapeutic benefit. There is great need for clinicopathologic correlation of the morbid anatomy of residual open lesions in patients converting their sputa during prolonged combined chemotherapy.

40. The Role of Pulmonary Insufficiency in Mortality and Invalidism Following Surgery for Pulmonary Tuberculosis.

Edward A. Gaensler, David W. Cugell (by invitation),

Jean M. Verstraeten (by invitation), Sylvia S. Smith (by invitation)

and John W. Strieder, Boston, Mass.

The evaluation of pulmonary function studies for thoracic surgical patients has been often discussed in general terms. This is a report of mortality and disability among 460 consecutive patients after major thoracic surgery for tuberculosis whose pulmonary function had been defined preoperatively. The disease was far advanced in most cases (78 per cent). Clinical and physiologic follow-up studies ranged from 6 months to 6 years

Early (30-day) mortality was 4.3 per cent. Respiratory failure was the main cause of death. Cardiac arrest, the second-most important cause of death, could not be related to the degree of pulmonary insufficiency before operation but was always preceded by periods of hypoxia during anesthesia.

Late mortality (30 days to 6 years) was 3.9 per cent. During this period pulmonary insufficiency, always accompanied by cor pulmonale, ranked last among the causes of death. However, other late complications took a higher toll among patients with poor pulmonary reserve.

Total mortality was 5 per cent in patients with preoperative maximum breathing capacities above one-half of normal and was 40 per cent in those with lesser capacities. Patients who were considered too ill for any preoperative function studies did not survive surgery. If the pulmonary reserve was minimal, operation often proved fatal although roentgenograms and bronchospirograms, had shown no function on the involved side before surgery.

Conclusions based on statistical analyses and study of individual patients should help to prevent repetition of past mistakes and should lead to better criteria for evaluation of physiologic data.

41. Experiences with Enlarging the Indications for Tracheal and Bronchial Grafts.

Osler A. Abbott, Wm. E. Vanfleit (by invitation) and

Albert Roberto (by invitation), Emory University, Georgia

Since the initial descriptions by Gebauer of the cutaneous-bronchial graft the authors have had experiences with the use of this technique in the handling of several different lesions. Of particular interest has been the use of these grafts in children aged 4 and 10, and we have had opportunity to observe the course of these patients for two and three years since the placement of such grafts. The grafts have also been utilized in patients having major degrees of hypertrophic-type emphysema requiring lobectomy for carcinoma. Such grafts have been subjected to postoperative radiation. Massive grafts have been used to replace major concomitant resections of the lower trachea, carina and contralateral bronchus in patients with extensive carcinoma of the right upper lobe. The complications encountered with this have been instructive. The replacement of the carina and posterior wall of the trachea in a patient with carcinoid-type of bronchial adenoma is also described. The problem is discussed in detail and indications and contraindications are suggested and analyzed.

42. Bronchial Anastomosis and Bronchoplastic Procedures in the Interest of Preservation of Lung Tissue.

Donald L. Paulson and Robert R. Shaw, Dallas, Texas

Bronchial anastomosis and plastic reconstruction of the bronchus in the interest of preservation of lung tissue are relatively new developments in the field of thoracic surgery. A lesion of the bronchus no longer always requires resection of all the lung supplied by the involved bronchus. By means of various types of repair it is possible to excise a portion of bronchus and restore the bronchial continuity, thus salvaging a portion, or all, of the lung tissue distal to the point of excision.

The authors have used a variety of procedures to preserve good lung tissue in 13 patients. The lesions of the bronchus so treated include traumatic bronchial occlusion (2), bronchial adenoma (2), tuberculosis stricture (3), and bronchogenic carcinoma (6).

In the 7 patients for whom bronchial resections and anastomoses or bronchoplastic procedures were done for benign lesions, a total of 3 lungs and 6 lobes of lung were preserved that would otherwise have been sacrificed.

Of the 6 patients in whom a bronchial reconstruction was done following resection for bronchogenic carcinoma, a total of 7 lobes of lung were preserved. Three patients have died of the carcinoma from 4 months to 1 year following operation. The remaining 3 patients are alive and well 6, 8, and 14 months after operation respectively.