RESECTION PULMONARY - Postgraduate Medical Journal · RESECTION FOR PULMONARY TUBERCULOSIS ByW.P. CLELAND, M.R.C.P., F.R.C.S. Surgeon, Brompton ChestHospital, Thoracic Surgeon, King's

305

RESECTION FORPULMONARY TUBERCULOSIS

By W. P. CLELAND, M.R.C.P., F.R.C.S.Surgeon, Brompton Chest Hospital, Thoracic Surgeon, King's College Hospital

and Postgraduate Medical School of London

Removal of tuberculous organs or tissues haslong been an accepted and successful form oftreatment in ' surgical ' tuberculosis. Lesions inthe kidneys, the genital organs in both sexes,cervical lymph glands and in certain bones andjoints have all been treated in this way with goodor excellent results even before the advent ofstreptomycin.The lung, however, has until recently defied

such treatment. Deliberate attempts were madeearlier to resect tuberculous lungs in certaindesperate situations, and some tuberculous lesionswere resected unwittingly in mistake for otherconditions. With few exceptions, these earlyresections ended in disaster with the developmentof broncho-pleural fistulae and tuberculous infec-tion of the remaining lung, the pleura and thewound.

However, during the last decade considerableprogress was made in thoracic surgery, much ofwhich had a direct bearing on the problem ofresecting the tuberculous lung.The most important of these changes are:i. The development of the technique of dis-

section pneumonectomy and lobectomy with theisolation and individual treatment of the varioushilar structures. This resulted in a more exactknowledge of the anatomy of the lung hilum whichin turn paved the way for segmental resections.

2. Improved anaesthetic methods which enabledthe anaesthetist to prevent the aspiration ofinfectedtuberculous material from the diseased into thenormal healthy areas of lung. Cuffed tubes,intrAbronchial blockers and the use of posture(face down position) now provide adequate controlof secretions in the average case.

3. A better appreciation of the part that deadspace plays in determining the onset or persistenceof pleural infection. Early elimination of deadspace after resection is one of the best possiblesafeguards against the development of pleuralinfection. Carefully placed drainage tubes, theuse of suction drainage, the employment of

phrenic paralysis with or without a pneumoperi-toneum and thoracoplasty all encourage the rapidand complete obliteration of the residual space.

4. Streptomycin. Probably the most importantsingle factor which enabled resections to be under-taken safely was the introduction of streptomycin.This drug is now used extensively in preparing foroperation, as an ' umbrella' during and afteroperation, and for the control of some of the post-operative complications.There is a marked difference between the

complication rates of cases treated before and thosetreated after the introduction of streptomycin, eventhough the former are a relatively small group andrepresent the earlier cases to be treated byresection. Recent work suggests that the compli-cation rate for streptomycin resistant cases issignificantly higher than for those with sensitiveorganisms.The efficiency and safety of streptomycin is

increased by the simultaneous exhibition of P.A.S.or isoniazid and one or other of these drugs shouldalways be administered with streptomycin if onlyto diminish the chance of streptomycin resistancedeveloping.During the past five or six years resections have

been used in the treatment of tuberculous lesionson an ever wider scale. (See Table 3). It hasbeen amply demonstrated that the operation isfeasible in many cases and can be carried out witha low mortality and little morbidity. The surgicaland technical side of the problem seems to be on asound basis. There still remains uncertainty,however, concerning (i) the indications forresection. (2) the late progress of patientssubmitted to resection and how these compare withother well established forms of treatment parti-cularly thoracoplasty. (3) the effects on immunityof removing the whole or the greater part of thetuberculous disease from a patient. (4) theimportance of antibiotics used in conjunction withsurgery.

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306 POSTGRADUATE MEDICAL JOURNAL _tine I954

TABLE I

CASE CLASSIFICATION IN RELATION TO OPERATION AND HOSPITAL MORTALITY

Type of Case Pneumonectomv Lobectomy Segmental Resection Totals

Good risk 14 (no deaths) 42 (no deaths) 34 (no deaths) 90 (no deaths)

Fair risk 30 (i death) 33 (no deaths) 8 (no deaths) 7I (I death)

Poor risk 2I (4 deaths) II (5 deaths) - 32 (9 deaths)

Total 65 (5 deaths) 86 (5 deaths) 42 (no deaths) 193 (io deaths)

TABLE 2

OPERATIONS WITH MORTALITY AND COMPLICATION RATES

Hospital Late Empyema LateTotals mortality mortality Fistula without fistula reactivation

Pneumonectomy 65 5 I 0 I 3 4

Lobectomy 86 5 I 4 I 9

Segmental resection 42 0 I 2 2 4

Totals I93 10 12 7 6 17

TABLE 3

BIENNIAL RECORD OF OPERATIONS WITH HOSPITAL (H.) AND LATER (L.) MORTALITIES

Pre streptomycin 1948-9 1950-I 1952-3

Pneumonectomv .. 4 2 H. 20 3 H. 35 2 H. IO O H.oL. 5L. 4L. II.

Lobectomy . . I OH. 9 o H. 32 3 H. 45 2 H.IL. I L. oL. oL.

Segmental resection - I O H. I6 O H. 25 O H.oL. I L. oL.

Totals .. .. 5 2H. 30 3 H. 83 5 H. 8o 2 H.I L. 6 L. 5 L. I L.

The Advantages and Disadvantages ofResectionThe possible advantages of resection are (i) the

extirpation of the more obvious and activetuberculous lesions with the removal of ' toxicfoci 'should leave the body the less formidable taskof controlling the remaining disease. This fallsinto line with the impression that the removal ofmajor foci of disease frequently has a beneficialeffect upon minor foci. (2) The function ofremaining lung tissue is not impaired to the sameextent as occurs in collapse therapy, particularlyafter thoracoplasty, as there is less interference withthe chest wall and its movements. (3) There is nofear of unclosed cavities or residual bronchiectasiswhich sometimes occur after thoracoplasty.(Cavities persist in some io to i5 per cent. ofthoracoplasties and plombs.) (4) In certain caseswhich are undiagnosed or unproven, resection is

advisable in case the lesion is due to a more seriouscondition such as a carcinoma. This particularlyapplies to th'- solitary rounded lesions.

Against this we have to consider the followingpotential disadvantages.

i. There is a somewhat greater risk at operationand a higher post-operative complication rate thanoccurs with thoracoplasty.

2. Post-operative complications, when they dooccur, are often of a more serious nature (e.g.,broncho-pleural fistula and empyema) and aremore likely to end in disaster.

3. Uncertainty about the stability of the patientfrom a long-term point of view. Enough timehas not yet elapsed to provide the answer to thisquestion. (Thoracoplasty cases show remarkablestability over the years.)

4. Problems created by the production of a deadspace following removal of lung tissue.

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CLELAND: Resection for Pulmonary Tuberculosis

(a) Persistence of a dead space (pleural) mayresult in the development of an empyema.

(b) If remaining lung tissue over-expands in anattempt to close the space, re-activationof latent tuberculous foci in the lung mayoccur.

5. A surgeon may be driven, for technical orpathological reasons, to remove more lung tissuethan was originally intended or desired with thepossible sacrifice of normal lung tissue, and inborder line cases the risk of producing a respiratorycripple.

6. Inadvisability of carrying out a resection ifthere is active disease in any of the lung tissuewhich is to be left behind. This really limitsresection to patients who have unilateral uncon-trolled disease.

Indications for ResectionIn the management of a tuberculous patient it is

usual to see what can be achieved by bed rest andchemotherapy before embarking on more elaboratemeasures. This enables the clinician to assess thepatient's powers of resistence and his ability tofight his own disease; this information may oftenbe culled from a careful study of the clinical courseand serial radiographs in chronic cases, but inothers it can only be obtained after a period ofobservation and therapeutic trial.With this information available the clinician is

better able to decide whether further measures arenecessary to control the disease bearing in mindsuch factors as temperament, occupation andsocial conditions.

In the past minor collapse measures, such asartificial pneumothorax, phrenic paralysis andpneumoperitoneum were initially employed withsome measure of success and only when thesefailed to control the lesion or were contra-indicatedwere the major surgical methods of collapsetherapy employed.The standard procedure in such instances was

the thoracoplasty. This operation has been in usefor many years and has stood the test of time. Notonly does it give a high percentage of good resultswith regard to cavity closure and sputum con-version, but the long term stability of the patientafter operation is well known. Extrapleuralpneumothorax and plombage are essentiallyvariations of a thoracoplasty designed to overcomesome of the disadvantages of the latter or to extendits indications.

It is well known that there are certain types ofdisease which do not do well with thoracoplasty,and some of these can now be treated by resectionwith more satisfactory results. The majority ofclinicians are in agreement about these cases and

they can be classed as the absolute indications forresection.

There remain, however, a large number of caseswhich could equally well be treated by eithercollapse therapy or resection, constituting a groupof relative indications for resection. In this groupthe decision to resect depends largely upon thebias of the particular surgeon or physician con-cerned. The immediate results are fairly com-parable which ever method is employed. Muchwill depend on whether the long-term results(5 to io years) are better in one or other group.There remains a group where resections are

contra-indicated but where collapse therapy is stillpracticable and finally an all too large group whereno radical treatment is possible.

I will now discuss the indications for resectionfrom the point of view of the local lesion alon2.However, it must be emphasised that this is not theonly consideration in planning treatment and thatlesions elsewhere in the lungs, other pathologicalconditions such as emphysema, asthma, cardio-vascular disease etc., and particularly a poorrespiratory reserve all come into the picture andmay force one to carry out treatment which is notideal but is either safer or more practicable.

Absolute Indication for Resectioni. Solid-Tuberculous Lesions. ' Tuberculoma'

(Figures i and 2.)This is a group comprising several differing

pathological entities (progressive primary lesion;circumscribed areas of caseous pneumonia-thetrue tuberculoma; blocked tuberculous cavitiesand tuberculous abscesses of the bronchus distal toa bronchial occlusion). They are, however, aradiological entity and are for convenience, there-fore, grouped together as the diagnosis is usuallyonly made after removal of the lesion. In certaininstances a firm diagnosis of tuberculosis cannotbe made and in such cases cancer is a possibilitywhich should demand resection.

It is generally accepted that a lesion of this typewhich is larger than two centimetres in diametershould be removed. This is based on the assump-tion that the body cannot absorb and heal a lesionof this size and at best can only encapsulate thelesion. There are moderate risks of breakdown,excavation and spread.

2. Lesions Associated with Broncho-StenosisMany tuberculous lesions are either essentially

due to, or complicated by relative or absolutestenosis of the related bronchi. The stenosis mayprevent adequate healing and it is probable thatcollapse therapy will only serve to aggravate thestenosis. If healing of the tuberculous process hasoccurred, residual bronchiectasis due to the

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308 POSTGRADUATE MEDICAL JOURNAL June 7954

...

FIG. i (a)FIG. I.-Lobectomy for a solid lesion-so-called

'Tuberculoma.' (a) P.A. tomogram through the' tumour.' Neither calcification, cavitation, norsatellite nodules present to indicate the correctaetiology. (b) Specimen shows a solid tuberculouslesion exhibiting concentric layers or ' onion '

effect and calcification in adjacent hilar glandsindicating that the lesion is a progressivc primaryfocus.

obstruction is likely, and may well producesymptoms and require treatment.The presence of active tuberculous disease of the

bronchus at the site of division may mitigateagainst satisfactory healing of the stump and deter-mine the occurrence of a bronchial fistula. Incases where such disease is suspected or demon-strated, it is advisable to administer a long pre-operative course of streptomycin etc., in order toencourage healing of the bronchial lesion beforeembarking on a resection.

Stenosis may occur in any part of the bronchialtree from the periphery to the main bronchus, oreven the trachea. Stenosis of small bronchi willgive rise to caseous abscess formation in that partof the bronchus beyond the obstruction. (Bron-chial cold abscess.) This will appear radio-graphically as a round or oval solid focus but it isoften possible to see the thickened bronchusleading to the solid focus.More proximal lesions will produce segmental,

lobar or total atelectasis which is readily recognizedradiologically. When the larger bronchi are

::

FIG. I (b)

involved, greater amounts of lung tissues arerendered airless with defective bronchial drainageand so in this group we find a significent increase insecondary septic complications in the involvedlung. These may be severe enough to dominatethe whole clinical picture and mask the essentiallytuberculous nature of the condition.

Wheezing, paroxysmal coughing, persistentpositivity of the sputum without adequate explana-tion should all suggest the presence of a bronchiallesion but cases are found who present none ofthese features. Bronchoscopy is an essentialinvestigation and may reveal marked redness andswelling of the bronchial mucosa, ulceration,granulation tissue or varying grades of fibrousstenosis. The limitations of bronchoscopy, how-ever, in this connection should be clearly realized.It is only possible to examine the main and lobarbranches and the orifices of the first segmentaldivisions. Many lesions will thus remain beyondthe range of bronchoscopic vision. Broncho-graphy, particularly with the new water solubleiodine preparations, often gives invaluable informa-

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Yune I954 CLELAND: Resection for Pulmonary ruberctdosi9

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FIG. 2.-' Cold abscess' of bronchus, or ' bronchialpyocoele ' treated by segmental resection. (a) P.A.tomographs showing 2 solid rounded foci one ofwhich shows 2 small translucencies. (b) Lateral filmreveals that the lesion lies in the posterior segmentof the upper lobe. (c) Specimen showing 2 bron-chial abscesses. In both instances the bronchusimmediately proximal to the lesion was stenosed.These lesions represent dilated bronchi which arefilled with caseous material.

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310 POSTGRADUATE MEDICAL JOURNAL June 1954

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FIG. 3 (a)FIG. 3.-Ten year history of progressive tuberculosis.

Left pneumonectomy (1948) for destroyed lung.Poor risk case with much purulent sputum. Aliveand well 5 years after operation. (a) P.A. filmbefore operation shows a completely opaque leftlung containing a large apical cavity. (b) Specimenshows a markedly stenosed left upper lobe bronchusand gross bronchiectasis throughout the lung.

tion about the patency or otherwise of the moredistally placed bronchi.

Broncho-stenotic lesions produce importantsecondary changes in the bronchi and lung.Bronchiectasis is common and suppurative changesin the lung are frequent. Thoracoplasty in suchcases may result in partial or complete control ofthe tuberculous element in the involved area, butleaves behind a destroyed and useless portion oflung which may well lead to symptoms of cough,sputum and haemoptysis, severe enough to demanda secondary resection.

3. Lower Lobe DiseaseTuberculous cavities in the lower lobe are

particularly difficult to treat as the usual methodsof collapse therapy are either not as effective, orare more destructive of normal lung tissue than isthe case with upper lobe disease. A thoracoplasty,for instance, would involve the collapse of a greatdeal of upper lobe before the lower lobe could berelaxed. Phrenic paralysis combined with apneumoperitoneum gave hopes of success whenfirst introduced but experience has shown thatthis combination will close only about 50 per cent.

......::.........:

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FIG. 3 (b)

of cavities, and even of those closed a proportioneventually re-open.

For lower lobe cavities, the majority are agreedthat resection is the method of choice provided thedisease is not involving other parts of the lung.As regards the surgical problems, lower lobectomyis more favourable than upper lobectomy as it iseasier to obliterate the residual pleural space byelevation of the diaphragm. Lower lobe disease,however, is often associated with significant diseaseelsewhere in the lung which may well renderresection undesirable, and in these circumstances,other methods such as thoracoplasty, localizedplombage, cavity drainage or a combination ofpneumothorax, pneumoperitoneum and phrenicparalysis may be advocated.

4. Failed Collapse TherapyFailure of an artificial pneumothorax, thoraco-

plasty or plombage to close a tuberculous cavityafter a reasonable interval of time demands furtheraction. If efficient collapse therapy has not beensuccessful after about 9 months, and if during thistime, chemotherapy and postural retention hasbeen employed to encourage closure, it is safe toassume that the method is unlikely to succeed withthe further passage of time. If one form ofcollapse therapy has failed it is unlikely that othermethods will succeed, and under these circum-stances it is usual to recommend resection. After

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CLELAND: Resection for Pulmornary Tuberculosis

an artificial pneumothorax there are no specialtechnical difficulties but the removal of a lobe aftera thoracoplasty or a plomb is technically a moredifficult operation but one which gives satisfactoryresults and presents no problems concerning theresidual dead space which is already well nighobliterated by the previous collapse procedure.

5. Destroyed Lobe or Lung. (Figure 3.)This is the term applied to the condition where

the tuberculous disease has swept through anddevastated a complete anatomical unit such as alobe or lung. Little or no functioning lungremains whilst the bronchi are dilated and inertand often the seat of secondary infection. Somc-times the tuberculous element has burnt itself outleaving a bronchiectatic and fibrotic lung.Although collapse therapy in such cases has beenused with success in the past and is occasionallythe only practicable form of treatment today itinevitably leaves behind a bronchiectatic anduseless lung which may later give rise to trouble-some symptoms.

Such cases are better treated by resectionprovided the remaining lung tissue is sound.So often, however, the rest of the lung is involvedso that resection is too hazardous, and in thesecases collapse therapy is not only justified but areasonable alternative.

6. Anteriorly Placed CavitiesCavities in the anterior segment of the upper

lobe, in the lingula or in the middle lobe aredifficult to treat by thoracoplasty owing to theirposition. Such cavities are undoubtedly besttreated by resection whenever it is practicable.

7. Cold Abscess of Bronchus. (Figure 2.)Recently attention has been drawn to a lesion

produced initially by a tuberculous focus in thewall of a small bronchus leading to obstruction ofthe latter either from a caseous mass or fromsecondary cicatricial contraction. As a result thebronchus distal to the obstruction becomes filledwith caseous material and has been termed a' cold abscess of the bronchus,' or ' bronchialpyocoele.' These lesions can often be recognisedclinically and radiologically. Their clinical courseis one with little systemic disturbance and toxicitybut is punctuated with exacerbations associatedwith a positive sputum. Radiologically theypresent as peripherally situated oval shadows witha thickened stem bronchus leading towards thehilar region. One or more small translucent areasare often seen in the opacity on tomography.

It seems unlikely that such lesions could beadequately and certainly controlled by collapsetherapy and resection is advised in those caseswhich are not quiescent.

8. Tuberculous BronchiectasisThree separate conditions are included in this

group. (i) Bronchiectasis which has incidentallybecome secondarily involved by tuberculosispresumably by lighting up a latent tuberculousfocus in its midst. (2) True tuberculous bron-chiectasis due to extensive involvement of thebronchi by tuberculous disease. (3) Isolated orpatchy bronchial dilatations which frequentlyoccur in the vicinity of tuberculous lesions. Thefirst two can only be adequately treated byresection if symptoms are present althoughconservative measures such as postural drainageand the antibiotics may help to reduce symptoms.The latter is an almost accidential bronchographicfinding and is very unlikely to give rise to symptoms(except occasional minimal bleeding) and will notdemand special treatment.

9. Tuberculous EmpyemaThe whole approach to the treatment of tuber-

culous empyema has changed since the introduc-tion of streptomycin and the practice of resections.Previously reliance was placed upon repeatedaspirations or total thoracoplasty to obliterate theempyema space whilst external drainage wasrequired for those with secondary infection or abronchopleural fistula.Now it is universally agreed that major surgery

gives far quicker and better results and hascompletely replaced the former regime except incertain special instances.A tuberculous empyema which is not associated

with uncontrolled or active disease in the under-lying lung should be excised (pleurectomy,decortication) but if there is disease in the lungunderneath this also should be excised with theempyema (pleuro-lobectomy, pleuro-pneumonec-tomy). Thoracoplasty is only employed in thosecases with significant disease on the opposite side.Although the operation is a severe one which is

sometimes accompanied by serious blood loss, theresults give relief of infection and toxicity and therestoration of lung function are well worth theadded risks.

Relative Indications for ResectionIn this group the indications for resection are

more debatable and not so universally accepted asthose mentioned in the previous section. Muchof the uncertainty is due to lack of information andthe position should be clarified in time.

i. Segmental LesionsThe earlier manifestations of pulmonary tuber-

culosis are often limited to one or two segmentswith the remainder of the lung free from disease.Such cases are usually treated initially with restand chemotherapy followed by some form ofsurgical treatment. Such a policy has beenevolved from the following observations andexperiences :- (a) Although rest and chemo-

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POSTGRADUATE MEDICAL JOURNAL

therapy may produce dramatic improvementresidual nodules frequently remain. (b) Wheresuch nodules persist, relapse is common onreturning to full activities. (c) Examination ofexcised ' quiescent' nodules often reveals thepresence of viable and virulent tubercle bacilli.There is thus an increasing tendency to recom-

mend prophylactic procedures to prevent suchrelapses. Surgical collapse therapy in the form ofthoracoplasty, plombage or extrapleurals areentirely satistactory but probably result in a greaterloss of lung function than would be the case with asegmental resection. There is an increasingtendency to carry out resections in such cases.

2. Cavities in the Apex of the Lower LobeI have already indicated that lesions in the lower

lobe are best treated by resection as collapsetherapy is difficult to apply. Cavities in the apexof the lower lobe are, however, a little morefavourably situated for collapse measures andthoracoplasties or localized plombage operationsare often practicable. The former, however,results in the collapse and consequent loss offunction in the greater part of the upper lobe.This is an advantage if the latter is diseased but ifnot it is an unnecessary sacrifice of functioninglung tissue. Localized plombage conserves morelung tissue but is a method which has not yet beengiven an adequate trial although results areencouraging. Resection has much to offer,particularly for isolated lesions in the apex of thelobe. Where, however, these are combined withupper lobe disease which would necessitate anupper lobectomy in addition, it is doubtful if thereis much to be gained from the functional pointof view as in such cases it will be necessary to do athoracoplasty in addition to the resection in orderto close the residual space.

3. Acute Tuberculosis. (Figure 4.)The majority of cases of acute pneumonic or

broncho-pneumonic tuberculosis respond ade-quately and often rapidly to rest and chemotherapy.Occasionally the response is disappointingly slowor incomplete, and in such cases resection shouldbe considered as it gives good results provided thedisease is limited to a lobe or a lung. Someconsider that resection is too radical and risky aprocedure and prefer to continue for long periodswith medical treatment. They argue that resolu-tion may eventually occur and it is not possible toforecast how much functioning lung tissue mightbe salvaged by these means. The individual casemust be judged on its merits but the possibilitiesof surgery for localized disease with toxic mani-festations not responding to chemotherapy must beborne in mind.

4. Tension CavitiesCavities are formed by a combination of ulcera-

tion and inflation and the majority of establishedcavities are thus strictly ' tension ' cavities andpressures of the gases within them are positive.The term ' tension ' or ' distension ' cavities,however, refers to large thin walled oval orspherical cavities usually found in the upper lobeor apex of lower lobe. Such cavities are moredifficult to close with a thoracoplasty than othersalthough closure can often be obtained if theoperation is carefully and logically carried out.This may often mean, however, an extensivecollapse with considerable encroachment onnormal lung tissue and an almost total thoraco-plasty may often be required. In such cases,resection has the advantage of leaving the remain-ing lung free to expand and thus ensuring bettersubsequent function.

5. Fibro-caseous upper lobe disease with orwithout cavitation provides the real bone ofcontention in the argument of resection versuscollapse therapy. This particular type anddistribution of disease is probably more commonthan most other varieties and in the past has givengood results with thoracoplasty. Complicationsare few and the percentage of unclosed cavities orsignificient (i.e. symptom producing) bron-chiectasis is small.The protagonists of resection maintain that

excision of these areas is advisable to remove theinfected foci, that resection even when combinedwith a small thoracoplasty is less deforming andcauses less reduction of lung function than astandard thoracoplasty and there is no risk ofunclosed cavities or bronchiectasis. Against this,however, resection does carry a small risk of theproduction of a broncho-pleural fistula or apicalempyema, both complications of some severityand importance.No clear cut plan is available in such cases and

only time and the long-term progress of theresection group will perhaps help to clarifythe issue.

Pre-Requisites for ResectionIt will have become obvious from the earlier

discussion on indications for resection that inmany cases there is little to choose betweensurgical collapse therapy and resection and that inthose cases where a resection is indicated it is notalways practicable because of lesions elsewherein the lung.The following factors will influence the decision

in such cases.(a) Disease in the Remaining Lung TissueAfter resection the residual lung tissue on the

same or opposite side not only carries on the wholerespiratory function but by its over-expansionpartly compensates for the loss of lung substance

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June 1954 CLELAND: Resection for Pulmonary Tuberculosis 313

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FIG. 4.-Acute pneumonic disease with cavitation.Left upper lobectomy, April, I953, 3 monthsafter acute spread. Space reduction by apicalthoracoplasty. (a) P.A. film after acute exacer-bation showing a cavity at the left apex and exten-sive infiltration at the base. (b) Left lateral filmshowing disease limited to upper lobe. (c) P.A.film 3 months after upper lobectomy. The lowerlobe occupies approximately its normal position.

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and helps to fill up the residual dead space. Thisover-expansion and associated increased ventila-tion may cause latent tuberculous foci to becomeactive; this is a most important considerationin planning a resection.The presence of active disease, particularly if

cavitated, in the lung to be left behind is a definitecontra-indication to resection at that time.Should it subsequently be controlled either bychemotherapy, the passage of time, or by surgerythen a resection could be re-considered. As avery rough guide to stability, one year withoutradiological change is regarded as a reliable index.

Should nodulation be present in the lung or lobewhich remains-even though it is regarded asquiescent, it is wise to prevent that lobe or lungfrom over-expanding by methods which will beoutlined later.

It will thus be apparent that a very carefulassessment of the whole of both lungs is necessarybefore operation. Good radiographs are anessential, and tomography almost equally so.Most information is derived from A.P. tomographsof the contralateral lung and lateral tomographs ofthe operation side. The latter are valuable inobtaining accurate anatomical data about the lesionand adjacent segments, but is not quite so suitablefor a routine survey of a lung owing to the widevariations in soft tissue shadows.

(b) Activity of DiseaseOne of the most difficult tasks confronting the

phthisiologist is the assessment of activity ofdisease. Fever, a raised E.S.R., loss of weightand radiological changes in serial films givecertain limited help but the decision often remainsremarkably difficult. If active disease is suspectedit is advisable to delay operation and continue withrest and chemotherapy. This applies even moreforcibly if active disease is seen in the bronchi atbronchoscopy.

If active disease is not obvious it is only neces-sary to give a short preoperative course ofstreptomycin.

(c) Streptomycin SensitivityMention has already been made of the value of

streptomycin in the preparation for operation andits use as a cover during the operation. It is rarefor an individual to reach the stage of operativetreatment without already having had a course ofstreptomycin.

There is a certain amount of evidence to suggestthat the complication rates in patients whosebacilli are streptomycin resistant is appreciablyhigher than in those that are sensitive. Unfortu-nately determination of resistance takes time andit is often impracticable to delay surgery pendingthe results. With intelligent anticipation, how-ever, such reports may often be obtained in time

and may well have an important bearing on thedecision as to the type of surgery to be carried out.

The OperationPreparation. Careful preparation for operation

should never be neglected as the operation isusually one of election and not an emergency.Short periods of rest and chemotherapy (i to 3weeks) are advisable beforehand during whichtime sepis elsewhere (teeth, nose and bronchi) canbe dealt with, breathing exercises can be institutedand coughing instructions given. Such a periodof inactivity immediately before operation isvaluable for observation and will ensure thatunsuspected fresh lesions are unmasked.

Anaesthesia. The most important considera-tion from the anaesthetic point of view is theprevention of aspiration of infected secretionsinto healthy lung. This is achieved by a variety ofways such as posture (face down position),endo-bronchial balloons and endo-bronchial cuffedtubes. There is probably little to choose betweenthe various methods employed by an experiencedoperator.

Operative Technique. It is not possible to givedetails of technique here but certain importantprinciples should be mentioned.

(a) Avoidance of contamination of the pleuralcavity.

(b) Extrapleural enucleation of adherent areas.(c) Avoidance of a long bronchial stump.(d) Careful bronchial closure.(e) In any segmental or lobar resection avoid-

ance of transgressing tuberculous disease.Never leave a raw surface which might bedoubtfully involved in tuberculousdisease.

As regards the extent of the resection theimportant considerations are to remove theoffending lesions with an adequate safe margin andin an approved anatomical manner and yetconserve as much normal lung tissue as possible.At the same time unnecessary risks should not betaken in leaving behind doubtfully active areas ofdisease. This latter consideration is one whichmay often necessitate the removal of more than wasintended and should always be borne in mindbefore operation. This is one of the inherentdisadvantages of resection therapy.The most conservative form of removal is the

excision of an isolated nodule (nodulectomy)followed by wedge resection for very limitedperipherally situated foci, segmental resectionlobectomy and pneumonectomy. In any onecase various combinations of the above may benecessary to eradicate the obvious lesions.

After removal of the involved tissue the surgeonis faced with the problems of rapid elimination

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_)une I954 CLELAND: Resecr;on for Pulmonary Tuberculosis 315

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FiG. 5 (a) FIG. 5 (b)FIG. 5.-Chronic cavitated disease in right upper lobe. Right upper lobectomy, May, 1953. Space reduction with

phrenic paralysis and temporary pneumoperitoneum. (a) P.A. film before operation showing infiltration andcavitation in the right upper lobe. (b) P.A. film 6 months after operation. The lower and middle lobes nowoccupy the upper half of the chest.

of the residual dead space without undue over-expansion of the remaining lung tissue.

In this connection the following observationsare relevant:-

I. Continuous and efficient removal of all airand fluid exuding from raw lung surfaces must beeffected by carefully planned tube drainage with orwithout the use of suction.

2. Small losses of tissue can usually be compen-sated for by expansion of adjacent lung segmentsand no further steps will be necessary.

3. Loss of a lobe or smaller loses associated withresidual infiltration must be compensated for by aspace reducing measure, such as phrenic paralysis,a pneumoperitoneum either singly or in combina-tion (Figure 5) or an apical thoracoplasty (Figure4) or plombage. In the case of an upper lobesatisfactory space reduction is obtained byremoving portions of the 2nd and 3rd ribs andstripping the pleura from the under surface of theIst rib but not removing it. Both thoracoplastyand plombage can be performed at the conclusionof the resection without placing undue strain onthe individual. Phrenic paralysis can readily bedone at the time of the resection but a pneu-moperitoneum is best induced a few days before

operation to allow the patient to become accom-modated to the presence of air in the abdomen.

4. After pneumonectomy, space reduction isoften adequately achieved by elevating theparalysed diaphragm with a pneumoperitoneumand relying on mediastinal migration and chestwall contraction to do the rest. If these factorsdo not appear to be adequate after 2 to 3 weeks, orif it appears that the opposite lung is expandingunduly, then a controlling thoracoplasty isadvisable. Thoracoplasty done at the same timeas pneumonectomy is advocated by some and canbe safely carried out in patients whose condition isgood but in others it is a greatly added burden andis probably more safely deferred for a few weeks.

Post-Operative Management andComplications

In the post-operative care of patients afterresection there are two overwhelmingly importantconsiderations.

i. Early and complete obliteration of pleuraldead space. Mention has already been madeabout steps to achieve this end taken during theoperation. After operation efficient tube functionmust be maintained at all times with water seal or

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suction according to taste. In this way air andfluid is removed as soon as it collects in thepleural cavity and the remaining lung is encouragedto fill the residual space. Failure to obliterate thisspace is one of the most important causes ofempyemata.

2. Removal of tracheo-bronchial secretions.There is no doubt that the accumulation ofsecretions in the bronchial tree is usually re-sponsible for atelectasis and for many of the earlypost-operative spreads of disease. After operationefficient coughing is very important. A vital rolehere is played by the physiotherapist but allconcerned, nurses and doctors alike, nmust beprepared to play their part in encouraging thecough. Frequent rolling in bed with breathingexercises at the same time, inhalations, expectorantcough mixtures and chemotherapy all have theirplace in the control of secretions.

Subsequent management of the case mustobviously vary but periods of bed rest and chemo-therapy are universally advised. The patient isfrequently kept in bed for three months afteroperation although he may be allowed up fortoilet purposes during the latter six weeks.Chemotherapy is continued for at least si) weeksafter operation, sometimes for much longerperiods. A further period of 3 to 4 months slowconvalescence is required and this is best carriedout in a sanatorium before returning home andto work.The three most impotant complications apart

from those which one may encounter after anyform of surgery are:

i. AtelectasisMention has already been made about the

prevention of this complication. Sometimes thedevelopment of atelectasis is quite silent and thediagnosis only made radiologically. More often,however, there is a febrile disturbance associatedwith difficult expectoration and reduction ofsputum. Tbe latter is usually thick and sticky.Physical signs consist of mediastinal displacementtowards the affected side, dullness and absent airentry or bronchial breathing. The X-ray showsa homogenous opacity in the place of the aeratedlung.

Treatment must be vigorous and initiallydirected at the encouragement of coughing andexpectoration. With modern chemotherapyfurther action is not desperately urgent providedsymptoms are minimal, but if the patient is toxic,dyspnoeic or distressed and aeration is notachieved early then bronchoscopic aspirationshould be carried out without delay. In very sickindividuals this can be carried out in the ward witha minimum of disturbance.

2. Broncho-Pleural Fistula. (See Table 2.)

This is undoubtedly the most dreaded of thecomplications of resection and carries a highmortality and morbidity. Persistent leakage ofair is frequent immediately after lobectomies andsegmental resections from the raw lung surface butsealing usually occurs within a few days. Thechief danger of such a leak is that it will preventfull expansion of the lung to fill the dead space.True broncho-pleural fistulae usually occurbetween the first and third week after operationand are almost always due to infection in thestump. The complication can be reduced bycareful bronchial suturing, the avoidance of a longstump and the avoidance of tight sutures.

Histological examination of the bronchus at thesite of resection shows tuberculous foci in themajority, and it is surprising that tuberculousinfection of the stump is not more frequentlyencountered. No doubt streptomycin used be-fore and after the operation plays an importantpreventative role.The development of a fistula is often heralded by

fever, and the production of blood-stained sputumsimilar to the fluid present in the pleural cavity.If the leakage is small, control is often possible byrepeated daily aspirations combined with activechemotherapy and healing may occur. Usuallyhowever, drainage will be required and theresultant empyema cavity and the fistula may takelong to heal and may well require further surgicalmeasures to close it.

Early thoracotomy and re-suture of the bronchusis advocated by some, but the results of suchmeasures are not very encouraging.

3. Empyema. (See Table 2.)There are two factors which together are

responsible for the majority of empyemata. Oneis failure to obliterate the pleural dead spacerapidly and completely, and the second is thedevelopment of a broncho-pleural fistula.The importance of maintaining efficient tube

drainage with the removal of all air and fluid as itappears has already been mentioned. It isusually unwise to leave a tube in the pleural cavityfor longer than 4 to 5 days owing to the risk ofintroducing infection along the tube track.Following the removal of the tube any furthercollection of air or fluid should be aspirated or ifexcessive a new tube should be introduced at adifferent site.

It is probably superfluous to mention that everycare should be taken to avoid contamination of thepleural cavity at the time of operation, though it issurprising how well minor degrees of soiling aretolerated.

Established pleural infection calls for regularaspirations of the pleural cavity with the removal

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CLELAND: Resection for Pulmonary Tuberculosis

of as much fluid as possible and the use of intra-pleural antibiotics. Aspirations should be re-peated daily until the infection subsides and thefluid no longer accumulates. Should aspirationsfail to control the infection, pleural drainageshould be carried out.An established empyema will often take a very

long time to heal and chronicity is common; thisis particularly so in the case of an apical empyemawhich may follow upper lobectomy and in suchcases an early thoracoplasty is often indicated.Late ComplicationsThe future status of resection in the treatment

of pulmonary tuberculosis very largely depends onthe question of late complications and particularlyon the long-term stability of the patients.

Reactivation of old disease or the appearances offresh infiltration does occur from time to timeand is more likely to appear where lung tissue hasbeen unduly expanded especially when small fociwere present in this area of lung. (Hence theadvisability of preventing over-distension byvarious measures already out-lined.) Such lesionsoften respond well to rest and antibiotics thoughoccasionally surgical measures are required.(See Table 2.)Tuberculous ulceration of the bronchial stump

occurs from time to time and may be responsiblefor haemoptysis and a positive sputum. Healingcan often be achieved by further administration ofantibiotics.

Late tuberculous infection of a pneumonectomyspace and late empyemata occur very occasionallyand are notoriously difficult to treat at this stage.Results of OperationAs it is only about five years since resections for

tuberculosis were carried out in any number it isnot possible to give a really long-term follow-upreport at this stage. However, it is possible toout-line the immediate complications and resultsand give a medium-term follow-up on a moderateseries.The results of any series of surgical operations

are meaningless unless one knows much of thebackground against which the cases are treated.Not only must one know the various indicationsfor operation but something of the approach ofboth the surgeon and his physicians to surgery.Carefully selected cases should have a negligiblemortality and morbidity. But if only such casesare treated then many deserving patients will be

denied the prospect of cure or amelioration of theirsymptoms even though the risks are high. Asurgeon's figures will therefore depend verylargely at what point he draws the line ofinoperability. The figures given here representall my own personal cases and are designedmainly to indicate trends in the treatment anddemonstrate that even with a fairly radical out-lookthe mortality rates and morbidity figures are notexcessive or prohibitive.

In Table i the cases have been grouped accord-ing to an assessment of the operative risks intogood, fair and poor risks based on a considerationof the extent and type of the disease, age, co-existing conditions such as emphysema, bronchitis,amyloid disease, diabetes, etc. The figuresindicate a preponderance of poor risk cases in thepneumonectomy group and none amongst thesegmental resections. It also demonstrated themuch higher mortality in this group but here asalvage rate of 50 per cent. is well worth while asmany of these cases were quite desperate riskswith a very limited prospect without surgery.Table 2 shows the hospital and late mortality

for the three types of resection and the more seriouscomplication rates. Of the ten late deaths afterpneumonectomy four were not directly attributableto pulmonary tuberculosis but this high figureindicates the greater risk that a patient with onelung carries especially with regard to non-specificpulmonary infections.

Table 3 illustrates a decreasing number ofpneumonectomies and corresponding increasesin lobectomies and segmental resections fromI948 to 1952. This is largely due to a moreconservative surgical approach and the conserva-tion of normal lung tissue whenever possible.

Improvement in these figures should be expectedwith increasing knowledge and experienceparticularly as regards the selection of cases.

ConclusionIt will thus be seen that the removal of tuber-

culous lung tissue can be safely carried outwithout undue mortality or morbidity. Theoperation has opened up fresh fields and has addeda very powerful weapon to those already combatingthis disease. The final status of this type ofsurgery has yet to be agreed; that it will be animportant one can hardly be denied.

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Documents

RESECTION PULMONARY - Postgraduate Medical Journal · RESECTION FOR PULMONARY TUBERCULOSIS ByW.P. CLELAND, M.R.C.P., F.R.C.S. Surgeon, Brompton ChestHospital, Thoracic Surgeon, King's