Lung Resection in the Treatment of Pulmonary Tuberculosis* Resection in the Treatment of Pulmonary Tuberculosis* J. F. NUBOER, M.D. Professor of Clinical Surgery, University of Utrecht;

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  • VOL. 48, No. 6 November, 1956 407

    Lung Resection in the Treatment of Pulmonary Tuberculosis*J. F. NUBOER, M.D.

    Professor of Clinical Surgery, University of Utrecht;Head, Department of Surgery, Utrecht University Hospital, Utrecht, Holland

    IN the period before World War II there was ahigh degree of agreement in the Western Euro-

    pean countries regarding the treatment of pulmon-ary tuberculosis. The treatment consisted of a moreor less rigorous sanatorium regimen which wasoften supplemented by collapse therapy. Onlyas to a few details was there any difference ofopinion. In the Netherlands, for example, thesanatorium treatment was carried out extremelystrictly and a large proportion of cavities washealed by those means only. Intrapleural pneumo-thorax was little used and only when the processhad largely become inactive. As a result of this,one saw but rarely, on the one hand, tuberculousempyemata after application of intrapleural pneu-mothorax, but on the other, the application of thistherapy was frequently unsuccessful in the laterstages of the disease, on account of extensiveadhesions. For this reason extrapleural pneumo-thorax was extensively used in this period.

    Apart from these relatively slight differences,there was a large degree of agreement, as to thebest method of treatment. With the introductionof the antibiotics the situation changed completely.As a result of the anti-tuberculosis organization,set up before the war in the Netherlands, prac-tically every case passed through the tuberculosisdispensary and the treatment was from the outseteither conducted or controlled by the lung physi-cian. When it appeared, sometime after the intro-duction of streptomycin, that after long continuedapplication of this drug resistance could develop,in certain cases remarkably quickly, it becamenecessary to take account of this possibility at thebeginning of the treatment of each case. We havetherefore been extremely economical with strepto-mycin in the Netherlands, particularly in thosecases where the possibility of eventual surgicaltreatment had to be considered. A large proportionof the patients treated surgically by us, had re-ceived no streptomycin before the operation. The* Read at the 38th Annual Meeting of the John A. Andrew

    Clinical Society, Tuskegee Institute, Alabama, April 8-13,1956.

    problem of resistance to this drug in surgical caseswas of little significance. There has thus developedin this respect, a definite difference in the modeof treatment in different countries.

    In France, for example, every case of tubercu-losis receives streptomycin, I.N.H. and PAS fromthe beginning, so that in practically every casecoming to operation, one should be prepared forresistance to one or more of these substances. Ihave also the impression that in England one tendsto apply the chemotherapeutic and antibioticagents on a much larger scale, and this in myopinion, leads to limitation in the application ofresection therapy.

    These differences in therapeutic methods, makeit important to compare large series of treated pa-tients. However, in such a chronic disease as pul-monary tuberculosis, it is only possible to discussdefinite results after the passage of at least 10years and the time is nearly ripe to draw conclu-sions. It may, however, be of value to report alarge series of treated patients and to discuss theresults in those cases treated between 5 and 10years ago.Lung resection for tuberculosis has been carried

    out in the Netherlands for approximately 10 years.In the University clinic of Utrecht, up to March1, 1956, 1173 lung resections were carried out fortuberculosis, 1161 under cover of chemotherapeu-tic and antibiotic drugs.

    Pulmonary tuberculosis is a medical disease.The majority of sufferers from this condition maybe clinically healed by medical treatment only;surgical therapy, including lung resection, shouldreally only be considered when medical therapyhas failed. In the Netherlands, despite this factthat resection therapy is carried out on a largescale, it is nevertheless utilized for not more thanapproximately 30 per cent of sanatorium patients.

    It is not only so, that lung resection is indicatedonly when medical therapy has preceded operation,but it is also of the greatest importance, that thispreoperative treatment of the patient has been as

  • 408 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1956

    complete as possible. A strict sanatorium treatmentis essential, preferably with absolute bed rest,which includes mental rest. At the same time it isadvisable to administer PAS, which may, if neces-sary, be combined with INH. Streptomycin is, asa rule, not given as preoperative therapy in Dutchsanatoria. However if this drug is used, this occursonly on special indication, e.g. in the presence ofhematogenous spread or tuberculous bronchitisand in those cases with extensive processes, whichhave not responded to the other medical treat-ments. One tries however, in view of the possi-bility of a future operation, to reserve streptomycinfor the postoperative treatment of the patient andto control its use in such a way that resistance tothe drug does not occur.

    If, after six to twelve months sanatorium treat-ment, healing has either not occurred, or is stillso incomplete that the probability of recurrenceis great, surgical therapy must be considered.

    In the consideration of resection therapy forpulmonary tuberculosis one must always bear inmind the fact, that lung tuberculosis is not a local-ized process. It affects as a rule a much largerarea of the lung than the results of clinical in-vestigation indicate.

    It is thus certain that by surgical removal of alobe, or even an entire lung the disease processcannot in the large majority of cases be completelyremoved. On this account lung resection for tuber-culosis should always be regarded as an incompleteoperation and it is of great importance to keepthis fact constantly in mind. Experience has taughtus that the results of surgical treatment of tuber-culosis of the other parts of the body are as arule unsatisfactory, unless it is possible to removecompletely all diseased tissue. In any operation,tissue planes are separated, blood and lymph ves-sels opened and the barrier which the body hasbuilt against spread of the disease is broken down.In connection with the operation it was not seldomseen that a dissemination or local spread of thetuberculous process occurred.

    Experience following resection of tuberculouschanges in the lung was not more favourable. Theoperative mortality was appallingly high, accordingto Thornton and Adams, 45 per cent for pneu-monectomy and 25 per cent for lobectomy.1 Thefatal outcome was usually a result of dissemina-tion, reactivation or bronchial fistula development.

    In a small series of 12 cases treated by us in 1946,at a time when chemotherapeutic agents and anti-biotics were not available, we had a mortality of25 per cent.

    Since the introduction of the use of chemo-therapeutics and antibiotics, the state of affairshas completely changed. Streptomycin in particularhas a powerful action in fresh tuberculous inflam-mations and it appears to be possible by its use toprevent dissemination and early local establish-ment and growth of tubercle bacilli. By the use ofstreptomycin the incomplete removal of a tubercu-lous process was freed from one of its greatestdangers.

    It was unfortunately soon to become evidentthat the tubercle bacillus can become resistant toall of the active anti-tuberculous drugs. Shouldresistance against all these substances develop, thesituation is then precisely the same as it was inthe days before these drugs were available. It ishardly remarkable, therefore, that the results ofresection therapy in the presence of drug resistanceare so unsatisfactory and that the likelihood of thedevelopment of bronchial fistulae and dissemina-tion is so great. On this account it is advisable toconsider operation only when there is susceptibil-ity to at least one of the above named substances,and, in view of the fact that of these the mostpowerful is streptomycin, it is of the greatestimportance that the bacilli of the patient be stillsufficiently sensitive to this drug.Lung resection for tuberculosis has not thus as

    object the removal of all tuberculosis tissue. Theintention of the operation is rather to assist abody, not of itself capable of spontaneous healing,in the attainment of a clinical cure. The surgeon,therefore, must remove those parts which standin the way of a cure or which have become uselessto the body or dangerous to life because of seriousanatomical changes. There are however processessuch as bronchogenic disseminations which showin general a great tendency to cure and these may,if not too large or too extensive, be left behindundisturbed after the removal of the most seriouslyaffected areas. This opinion is common to manysurgeons who have a large experience in this field.

    There should be little difference of opinion inthe matter of what constitutes functionally worth-less or dangerous parts of a lung. If there is abronchial stenosis with bronchiectasis and reten-

  • VOL. 48, No. 6 Lunig Resec-tion in the Treatmenit of Pulmonary Tube rculosis 409

    tion of secretion, or if a lobe or an entire lungbe practically destroyed by multiple cavity forma-tion, the retention of these parts is of little valueto the patient; they constitute moreover a risk onaccount of a possibility of extension to the remain-ing healthy lung tissue.

    It is more difficult to answer the question as towhich of the more limited changes stand in theway of a clinical cure. On the basis of experiencethe Dutch surgeons have come to the conclusionthat it is mainly those foci of lung phthisis, fociof hematogenous origin arising after the primarytuberculosis, usually in the apical and dorsa