Pulmonary Decortication*

Transcription

1 Pulmonary Decortication* FRANK BORTONE, M.D., F.C.C.P.i" Jersey City, NewJersey Pulmonary decortication is, relatively speaking, an old operative procedure, which gained a fresh impetus during the second world war. George R. Fowler1.2 performed this operation in 1893 with gratifying results in all cases of old empyemas where pulmonary tuberculosis had been excluded, and the patient's condition permitted major surgery. Delorme- in 1894 performed an operation similar to that of Fowler. Briefly the operation consists of widely opening the thoracic cage either by incision through the fifth intercostal space, or by excision of the sixth rib, and of extirpating the visceral, diaphragmatic and parietal pleurae; where indicated, visceral and diaphragmatic pleurectomy alone is adequate. Post operatively air-tight, water-sealed, or in some cases suction drainage is used. The drainage tube is removed as soon as the lung has fully expanded. Due to the extraordinary developments in anaesthesiology, the discovery and use of new drugs including antibiotics, better understanding of pre-operative preparation and post-operative care, this procedure is now applicable to many pleuro-pulmonary pathological conditions. It has, for example, partially solved the problem of the unexpanded post-pneumothorax lung with or without effusion. We are now performing pleurectomy in such cases provided, after careful study of all previous chest x-ray films including laminographs, we are convinced that the cavity is closed, and the original disease arrested. In one case the un expanded post-pneumothorax lung, which had existed nine years, became fully expanded the first day post-operatively (Figures 1,2 and 3). These same criteria, and operative procedures apply to tuberculous empyema for which we formerly did thoracoplasties. The results were not always good, as a slit empyema cavity often remained. Then, we performed various modifications of the Schede operation. Often, after subjecting the patient to several surgical procedures a draining sinus remained. As a result of this experience in the old cases, on whom we had performed thoracoplasty for closure of tuberculous empyema, and had failed, we are now *Address given at the Annual Meeting of the Society of Surgeons of New Jersey, held at the Jersey City Medical Center, Jersey City, November 16,1949. ichief of Thoracic Surgery, Berthold S. Pollack Hospital for Diseases of the Chest, Jersey City Medical Center. 97

2 co CX) :ll )- tl3 o Z t>:l FIGURE 1 FIGURE 2 FIGURE 3 F igure 1: Unexpanded post pneumothorax lung of nine years duratlon.-figure 2: One day post-operatively.-figure 3: One year post-operatively... c 9' co

3 Vol. XX PULMONARY DECORTICATION 99 following up with decortication, rather than the Schede operation, with good results. Where we had performed thoracoplasties to close cavities in upper lobes, in which there was an associated tuberculous empyema, or when empyema developed after thoracoplasty which had failed, we are now performing lobectomy plus decortication of the remaining lower lobes with good results. The experience acquired by physicians with chest injuries during World War II has placed the treatment of hemothorax on a sound basis. Now we first do thoracentesis. Neglected organising hemothorax may eventuate in a fibrothorax which may become infected. Procrastination in the treatment will permit such advanced organisation along the visceral pleural surface that the lung becomes encased in fibrous tissue so dense that its expansion cannot occur, The best treatment therefore, as soon as the patient's condition warrants, is to open the pleural cavity, evacuate the blood clots and perform pulmonary decortication. This operative procedure also has revolutionized the treatment of non tuberculous empyema. The majority of cases recover with modern drug therapy coupled with repeated thoracenteses. If the temperature remains elevated in spite of this treatment, and fluid continues to accumulate, preventing the lung from re-expanding, a rib should be resected and tube drainage instituted. If the temperature and pulse rate improve however, but the fluid continues to collect, the thoracic cage should be widely opened, and pleurectomy performed followed by air-tight, water-sealed drainage. If, after rib resection and tube drainage, the temperature and pulse rate return to normal, but the lung still does not re-expand, rather than wait for months as we did in the past, we decorticate within a few weeks. If broncho-pleural fistula coexists, rib resection and tube drainage should be done immediately (Figures 4, 5 and 6). With these avenues of approach which eliminate months of draining and waiting and hoping for closure, we can conclude that the problem of chronic empyema has been solved. In closing, I want to stress the importance in the advances in knowledge of the adjuncts to the actual surgery: the improved techniques in anesthesia, the existence of effective drugs to combat infection, and the better management of the surgical patient. Because of these factors alone, the old operation of pulmonary decortication has returned to replace the deforming surgical procedures of the past. SUMMARY 1) Pulmonary decortication was successfully performed in the 1890's.

4 ... o,.., -, ;.. Z tll Z t>j FIGURE 4 FIGURE 5 FIGURE 5 Figure 4: Empyema, repeated thoracenteses not benefitted by drugs including antibiotics.-figure 5: Decortication, one day postoperatively.-figure 6: Present status, 26 days post-operatively.... c :; '"

5 Vol. XX PULMONARY DECORTICATION 101 2) In the last few years it has practically solved the problem of the unexpanded post-pneumothorax lung. 3) In tuberculous empyema decortication is now replacing the Schede operation. Cases of chronic non tuberculous empyema are also successfully treated by this operation. 4) Persons with hemothorax resulting from chest injuries can often be prevented from sustaining marked loss of pulmonary function if decortication is done sufficiently early. RESUMEN 1) El descortezamiento del pulmon fue llevado a cabo con buen exito un poco despues de ) En los ulttmos anos casi que ha resuelto el problema del pulm6n que no se reexpande despues del neumot6rax. 3) En el empiema tuberculoso el descortezamiento esta reemplazando la operaci6n de Schede. Casos de empiema cr6nico no tuberculoso tambien pueden ser tratados con buen extto mediante esta operaci6n. 4) En personas con hemot6rax secundario a heridas toracicas, a menudo se puede evitar la perdlda decidida de funci6n pulmonar si se emplea el descortezamiento 10 suficientemente temprano. RESUME 1) II ya deja longtemps que l'on pratique avec succes la decortication pleurale. 2) Dans ces dernieres annees, grace a cette intervention, on a trouve la solution pratique du problems que pose l'absence de reexpansion pulmonaire apres pneumothorax. 3) Dans I'empyeme tuberculeux, la decortication remplace maintenant I'operation de Schede. On peut traiter egalement avec succes par cette intervention les arnpyeme chroniques non tuberculeux. 4) Pour les individus qui sont atteints d'hemothorax, a la suite de traumatismes thoraciques, on peut souvent evtter une perte importante de la fonction pulmonaire si la decortication pleurale est pratiquee a temps.