Wednesday Morning, May 9,1956

9:00 A.M. Scientific Session: REGULAR PROGRAM.

33. Pulmonary Resection for Tuberculosis: A Five to Ten Year Follow up Study.

James D. Murphy and James M. Davis (by invitation), Oteen, N. C.

At the 1948 meeting of this Association we discussed the evaluation of pulmonary resection for tuberculosis in 70 streptomycin-protected patients. The study indicated that early results were highly satisfactory but that a permanent appraisal could not be made until a long period of postoperative observation had been completed.

We are now presenting a five to ten year followup study of 148 patients who had 150 resections: 83 pneumonectomies and 67 lobectomies or less during the period 1946 to 1950. Developments in the field of chemotherapy and surgery have been so dramatic that data gathered from the early group cannot accurately reflect the experiences being encountered today. It is felt, however, that this data is of great value as an account of the results achieved by excisional surgery during the pioneer days of streptomycin therapy.

The study reveals that 72% of 148 patients are at home with inactive disease from five to ten years after surgery. The road to this happy state, however, has been fraught with many hazards. The operative mortality was 2.7% but the total mortality has been 17.3%. In an effort to determine whether morbidity and mortality rates following resection have been reduced by changes in drug therapy we have also reviewed 100 consecutive resections done in 1954 and compared the results with those obtained in the original series.

34. The Role of the Chronic Occult Postresection Bronchial Fistula in the Reactivation of Tuberculosis: Pathogenesis and Treatment.

John W. Bell (by invitation) and E. M. Medlar (by invitation)

Sunmount, N. Y.

Little attention has been given to the association of chronic occult postresection fistulas and the reactivation of tuberculosis. Eight cases are described with fistulas presenting from three months to three years following segmental resection for tuberculosis.

The Clinical, Radiologic and Bacteriologic features essential for the diagnosis of chronic fistulas are discussed. The outstanding finding in each patient was the absence of overt signs and symptoms characteristic of the ordinary bronchopleural fistula. These occult fistulas occurred in the presence of known or unsuspected resistant bacilli in the resected tissues. Further, they were associated with the reappearance of persistence of bacilli in the sputum and, in most instances, with the phenomena of implantation tuberculosis in a pseudo cavity formed at the resection site.

With the exception of the first patient who died of pulmonary hemorrhage three months following primary resection, each of the remaining patients was successfully treated with secondary resection. Two specimens, therefore, were available in each case for the study or bacteriology and pathology. In particular, the age and behavior of the new tuberculosis process could be determined.

The significance of uncontrolled implantation tuberculosis is discussed. A surgical policy is suggested which avoids segmental resection in the presence of drug resistant organisms.

35. Extraperiosteal Plombage Thoracoplasty. Operative Technique and Results with 161 Cases with Unilateral Surgical Problems.

Norman J. Wilson, Orlando Armada (by invitation), William V.

Vindzberg (by invitation) and William B. O'Brien (by invitation),

Boston, Mass.

Between August, 1949, and June, 1954, extraperiosteal plombage thoracoplasty was performed upon 161 patients with unilateral surgical problems. A follow-up study of this group was done in June, 1955. Eighty-six were of the two-stage-type operation and 74 were the one-stage-type, the plombage being left in place. The longest follow-up in the latter group is three and two-thirds years. Ages of patients varied from 16 to 66 years. Thirty-six (22%) were over 50 years of age.

Preoperative X-rays revealed definite cavity in 141; honeycombing in five, three of which had positive sputum; no cavity in fifteen, nine of which were positive. Preoperative sputa were positive in 113 (70%). Forty-eight had negative sputa, but 40 of this group had definite cavity.

Tuberculous complications occurred postoperatively in one case (0.6%). Late complication occurred in 18 patients (11%). There were no postoperative deaths. Five have since died, three or coronary occlusion, one of metastatic carcinoma, and one of a severe unexplained enteritis.

Subsequent surgical procedures have been necessary in 23 (14%); 20 on the same side and in five on the contralateral side.

Follow-up in June, 1955, revealed five dead and 156 (97%) living. Of the 156 living patients, 145 (93%) are completely well. Four patients were lost to follow-up but are known to be alive.

These results indicate this to be a simple, safe and effective surgical procedure. It is possible that such collapse procedures are not being used often enough in this era in which resection has become so popular. In our experience results have been so good that this procedure occupies an important place in the surgical program and is the procedure of choice in certain types of cases.

36. Bronchographic Studies as a Guide in the Surgical Treatment of Pulmonary Tuberculosis.

F. J. Phillips, Anthony Lalli (by invitation) and Walter Buhler (by invitation),

Bartlett, Alaska

The average case of pulmonary tuberculosis seldom poses a treatment problem with the present antimicrobials. The pathological ravages of the older inadequately treated cases stimulate medical interest and create baffling problems in surgical judgment. At the Seward Sanatorium where an active surgical program is carried out, bronchography has been employed almost routinely in presurgical diagnostic evaluation procedures. More than 250 such cases have been so studied. There have been no serious reactions. Various radio-opaque substances have been used. With the use of post bronchogram bronchial dilators, retention of the opaque material has not been a problem. The technical problems of doing the procedure have been eliminated. Patients are routinely bronchoscoped and, when desired, bronchograms are done under fluoroscopic control by means of introduction of a rubber catheter through the bronchoscope while the patient's respiratory tree is still under the influence of the same topical anesthetic. The added diagnostic information has resulted in doing resections on many cases that would have been discharged without proper surgical treatment or left inadequately treated otherwise. Representative cases will be presented showing unanticipated cavitary and bronchiectatic cystic formations that would have precluded complete recovery.

37. A Clinical Evaluation of Decortication.

David H. Waterman, Sheldon E. Domm and

William K. Rogers (by invitation), Knoxville, Tenn.

In the eleven year period since the work of Burford and Samson revived interest in decortication and introduced new techniques, the worth of the procedure has been well established and widely recognized. Originally envisioned for empyema, hemothorax, and later for the unexpandable lung in pneumothorax, the indications for the procedure have been broadened to include a wide variety of conditions.

The authors have applied the technique in over 160 patients, a good number of which are cases having no residual pleural space, as in so-called "false re-expansion". It is the opinion of the authors that considerable clinical improvement can be brought about in patients in this latter category. Several cases of bilateral decortication are included in the series, as are cases in which the lung has been imprisoned for as long as 19 years. The results of pulmonary function studies including bronchospirometry in a representative group have corroborated the gratifying subjective clinical improvement reported by most of the patients in the series. Many individuals who were previously incapacitated have returned to full time activity with no demonstrable dyspnea.

The widened indications for the procedure are discussed and the clinical results of the series reviewed. It is felt that extensive utilization of the procedure is warranted.