Pulmonary Resection for Tuberculosis

Transcription

1 NOTES Pulmonary Resection for Tuberculosis Life Table Analysis of Results George,Johnson,,Jr., M.D., and Richard M. Peters, M.D. ilnionary resection as therapy for pulmonary tuberculosis has been the subject of many studies. The results, however, are frequently difficult to evaluate because of the variables in the saniple and in the follow-up. To niiiiiinize these shortcomings we have chosen the life table method of analysis to evaluate the results of pulmonary resection in an unselected state sanatorium population. METHOD All patients who have had pulmonary resection for tuberculosis at Gravely Sanatorium, Chapel Hill, N.C., during the period January 1, 1954, to July 15, 1963, have been reviewed. They had been transferred for surgery from The North Carolina Saiiatoriuin System" and were primarily from northeastern North Carolina. Patients of any age, sex, or race are admitted to this system regardless of financial status. The resident staff of the North Caroliiia Memorial Hospital (the University teaching hospital) performed the operations and cared for the patients in the immediate postoperative period. This study included 349 patients and 35 1 operations. The infor- From tlic 1)cp;trtment of Surgery, 1)ivision of Thoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, N. C. This work was supported by Grant KO SIH from The National Institutes of Health, U.S. Public Health krvice. Received for pu1)lication Mar *The Sorth Carolina Sanatorium Sjslern incliitles four hospitals for tu1)crculosis and chest diseases operated by the state of Sorth Carolina., 634 THE ANNALS OF 1HORACIC SURGERY

2 rnatioii was obtained from the patients' records, other hospitals, other physicians, local and state health departments, and on occasion froin letters to individual patients. The final information, which included age, sex, race, sputum status, operation, complications, deaths, and follow-up experience, was transferred to punch cards and tabulated. These data were analyzed and the differences compared by statistical methods using a five-year life table as described by Cutler and Ederer PI. Ileaths that occurred within SO days of the operation were classified as postoperative deaths regardless of cause. These patients were not included in the follow-up analysis and will be presented separately. It' a second pulnionary resection was performed on the same patient, the first was considered a failure and the second evaluated as a new operation. Planned bilateral resections were not included in this series. 'I'he preoperative sputuni was defined as positive if any one of the last three sputa obtained within the two months prior to operation contained acid-fast bacilli either by smear or culture..4 patient was listed as having a recurrence if the sputum contained acid-fast bacilli within six months following operation. Although a recurrence would have been considered if characteristic x-ray changes had developed, these did not occur without a positive sputum. Sociological characteristics of northeastern North Carolina, cases of tubcrculosis reported froiii this area, and the number of pullnonary resections performed at Gravely Sanatorium are listed by age, sex, and race in Table 1. Forty-one new cases of tuberculosis per year per 100,000 population were reported for the 35 counties covered by this report ill tlic period This compares to 29 per 100,000 for the entire ltnitcd States and 25 for North Carolina as a whole. 'I'he postoperative mortality was 3.4':/, (Table 2). An additional!i patients, or 2.6')&, died in the follow-up period from pulmonary disciise other than tuberculosis. Five patients below the age of 40 with extensive tuberculosis died folloiving pneuiiionectoiny. Three of these had complications of tuberculosis while the other 2 died froin pulnionary embolus and acute renal tuhlar necrosis, respectively. Five of the 60 patients who had complications (Table 3) went on to dc\fclop a recurrence of tuberculosis. Four of these had a bronchoplciiriil fistula, 3 following partial lobectotny. Two subsequently died lroiii tuberculosis.

3 TABLE 1. SOCIAL CHARACTERISTICS AND TUBERCULOSIS, NORTHEASTERN NORTH CAROLINA, AND RESECTIONAL THERAPY FOR TUBERCULOSIS, GRAVELY SANATORIUM ASD NORTH CAROLINA MEMORIAL HOSPITAL Population in Social Thousands Characteris tic 1960 Caucasian Male 425 Female 430 Negro Male 242 Female 257 Age (yr.) ii i of % of Total No. Cases of Total Cases of Population Tuberculosis, Tuberculosis Studied Studied i 19 I i I i i No. Resections, i i2 90 % of Total Resections

4 NOTE: Resection for Tuberculosis T.4Bl.E 2. POSTOPERATIVE MORTALITY RATES IN PULMONARY RESECTION FOR TUBERCULOSIS, GRAVELY SANATORIUM AND NORTH CAROLINA MEMORIAL HOSPITAL. No. Operations per Operation Performed -- Partial lobectomy Operative mortality Total lobectomy 0per;itive mortality Compound lobectomya 01x'r;i tive mortality Pneumonectomy Operative mortality A11 operations Operative mortality Age Group (yr;) Total % % % % 7% % 21% 0% % fil.ol)rctomy plus a segmental or sul>segmental rcscction. 10 0% % 12 8% % Y" 50 8 Yo 59 10% % ~ TABLE 3. COMPLICATIONSn OCCURRING IN PULMONARY RESECTION FOR TUBERCULOSIS Complications B ron ch o- Phrenic No. pleural Hemor- Wound Nerve Opwation Performed Fistula Empyerna rhage Infection Injury Totals Partial Iobectomy Total 1ol)cctomy Cot~i~~ouiici lobectomy Pncwnioiicctom y 'l'ol~ils II ~ :I'l.lic,se 66 complications occurred in 60 patients. Only 24 patients were lost before a five-year follow-up, 12 of whom moved out of the state and couid not be traced. 'I'able 4 is a life table similar to the ones constructed for each category studied. This one is an analysis of the five-year follow-up for the entire series and indicates that 93.4y0 of the patients should survive without a recurrence. The standard error for this prediction was "',. Eighteen of the 20 recurrences developed within two years. 'I'lie results of the life table analysis by age, operation, and preoperative sputum status are listed in Table 5. The differences in the results by age group and operation were not significant (P always greatcr than 0.5). A patient with a positive preoperative sputum, however. had a significantly greater chance of developing a recurrence than did one with a negative sputum (P = 0.001). This difference persisted regardless of type oe operation or age of patient. VOL. 1, NO. 5, SEPT.,

5 TAI3LE 4. LIFE TABLE ASALYSIS, PULJIOSARY RESECTIOS FOR TUBERCULOSIS, GRAI ELY SASATORIIIll,AND SORTH CAROLISA MEMORIAL HOSPII.AL So. M ho Diet1 During Inter\al \Vithtlrawn*~ So. from Stud) so. Pts. Lost to IVithout Curnulati\ c Intenal Xli\e at - Fo1low-u~ Recurrence so. so. Proportioil ProDortion Since I%egimiing Late, not Ihring During Effective Recurrences Recurrences Sun i\ itig Sun iving Opera tion of Post Tubercu- Interval Iiitervd h um her IVith IVi thou t IVi thout IVithout (yr.) Interval OP. losis (W yr.1 ($4 yr.) Exposed Death Death Reciirretice Recurrence (b , 2 2 ti OT3, ,969, ,996, I,995, ,934 Total Recu rreii ces 20 apatients known to have been alive without a recurrence on closing date of study (July 15, 1063, yet had not been followed five years. The last year followed gave W year experience. bsot included in statistical analysis.

6 ~ - ~~ NOTK: Kosrrtiori for Tubercitlosis TABLE 5. I.II;E TABLE \lellioi), I;I\'E-\'EAR SUR\'I\'AI. FREE 01; RECVRRESCE Age y'' yr yr. 50+ yr. -. ~~ 94%!) 5 :XI 87 "io 9 5 7" Operation Partial Total Compowid Lobectom y Lobectom y Lobectomy Pneunionectomy _ ~ ~ 87% 93% ~ 9570 ~~ 98% Positive 84 % Preoperative Sputum Status Negative 997" DISC U SSI 0 R' This report is one of an experience with resectional therapy for pulmonary tuberculosis for a general population. Tlie distribution of resections by age, sex, and race roughly corresponds to the incidence of tuberculosis for this area, indicating an unselected sample. In addition, the life table has allowed one to predict the results of therapy using all patients operated upon, and not necessitating complete follow-up. Thus the necessity of waiting until all patients have been followed five years is eliminated, and the results reflect those of current therapy. The low standard error for the total series enables one to predict a 95y0 chance that 90','& to!j6yo of a similar group of patients having similar operations at this institution would be free of disease in five years. Tlie high operative mortality after pneunionectoiiiy is due to an attempt to eradicate widespread tuberculosis in young patients. Had these patients been older, they would have been thought inoperable. Note that 6 of the 12 deaths occurred in this group; however, pneumonectoiny accounted for only one-sixth of the total patient experience. This high Inortality after pneumonectomy for tuberculosis has previously been emphasized by Zeppa and Peters [2]. Although the operative risk is high in these patients, the low recurrence rate would seem to justify pneumonectomy. The low mortality following lobectoiny is a reflection of disease confined to one area. The relatively high recurrence rate following partial lobectoniy niay be a reflection of a compromise operation to avoid the higher risk of other procedures. Compound lobectomy gave good late results if the patient survived the high postoperative mortality and complication rate. There was a significantly higher recurrence rate when the pre-

7 JOHNSON AND PETERS operative sputum was positive for acid-fast bacilli. However, this does not mean that one should persist with medical therapy until the sputum is negative. It is a reflection of more severe disease and of the resistance of the organism, and indicates the need for resectional therapy to remove the diseased area after a reasonable trial of medical therapy. In most of the positive cases in this series, the sputum had been consistently positive for six months or longer, suggesting that an adequate trial of medical therapy had been carried out. The overall results indicate that 90% of patients following resectional therapy for tuberculosis will be well at the end of a five-year period. An additional 3% will have succumbed from a pulmonary death. When appropriate, lobectomy would appear to be the treatment of choice for all age groups. Partial lobectomy should be reserved for the poor-risk patient with very limited disease who has had a quick conversion of the sputum. SUMMARY 1. Three hundred and forty-nine patients having resectional therapy for pulmonary tuberculosis at a state sanatorium have been reviewed. Follow-up information has been evaluated and presented by the life table method. 2. Operative mortality was 3.47,, and the complication rate 17%. 3. Ninety-three percent of the patients surviving operation were free of disease at the end of five years. 4. Patients who had a sputum positive for acid-fast bacilli preoperatively had a statistically significant greater chance of developing a recurrence of tuberculosis than did those who had a negative sputum. ACKNOWLEDGMENTS The authors are indebted to Dr. Bernard Greenberg and Mr. Kenneth Poole of the Department of Biostatistics, School of Public Health, University of North Carolina, for aid in the statistical analysis; to Dr. Herman F. Easom and Mr. Thomas Hinton of the Eastern North Carolina Tuberculosis Sanatorium for their aid in patient follow-up; and to Mr. Glenn A. Flinchum and Mr. Harold Sauls of the Statistics Section, North Carolina State Board of Health, for their aid in the sociological studies of tuberculosis. REFERENCES 1. Cutler, S. J., and Ederer, F. Maximum utilization of the life table method in analyzing survival. J. Chronic Dis. 8:699, Zeppa, R., and Peters, R. M. Some considerations concerning pneumonectomy in the treatment of pulmonary tuberculosis. Amer. Surg. 24:609, THE ANNALS OF THORACIC SURGERY