Surgical Salvage in Pulmonary Tuberculosis

Transcription

1 Surgical Salvage in Pulmonary Tuberculosis Norman C. Delarue, M.D., and Godfrey Gale, M.D. ABSTRACT The history of the surgical treatment of patients with pulmonary tuberculosis illustrates the rapidly declining need for operative intervention, even in the salvage area. Nonetheless the techniques which were largely developed and refined in treating complicated tuberculous disease have proved to be applicable in the management of challenging problems not involving tuberculosis. This report summarizes the results achieved by salvage resection, salvage decortication, and salvage thoracoplasty and indicates that the value exceeds the risk, even in critically ill patients. Emphasis is placed on the significance of persisting spaces and the methods of obliterating these cavities. Osteoplastic thoracoplasty is advised as a prophylactic technique and the tailored procedure as a definitive maneuver. When decortication is required in infected patients, enucleation of the empyema is preferable. The presence of a bronchopleural fistula in these patients creates life-endangering risks, and the security of closure can be improved by the utilization of intercostal muscle grafts. A technique for applying the graft is briefly described. S alvage procedures may be warranted when treatment has failed to arrest a disease process, when life-expectancy is threatened, or when return to normal activity is imperiled. In these situations the operative procedure may be utilized in patients who would not otherwise have been considered suitable for any operation because of either age, positive sputum, resistant organisms, chronic toxemia, or inadequate cardiopulmonary reserve. In the 20-year period between 1953 and 1972 (during which adequate chemotherapy was available), 146 salvage procedures (55 resections, 54 decortications, and 37 tailored thoracoplasties) were undertaken (Table 1). The mortality rate of 4.853, is considered acceptable. One hundred one of the patients (69y0) have remained free from disease during the period of follow-up observation (1 to 23 years). Of the 55 patients who had resection, 28 (51%) have been successfully rehabilitated; operative mortality was 9%. Subsequent death was due to cardiopulmonary factors in all but 2 patients. Decortication was employed for chronic tuberculous empyema in 27 patients, for fibrothorax in 17, and for inexpandable lung in 10. Fifty-one of From the Thoracic Surgical Service, Toronto General Hospital and Toronto Hospital, Weston, Ont., Canada. Presented at the Tenth Anniversary Meeting of The Society of Thoracic Surgeons, Los Angeles, Calif., Jan , Address reprint requests to Dr. Delarue, 150 St. George St., Toronto, Ont., Canada M5R2M8. 38 THE ANNALS OF THORACIC SURGERY

2 Sirrgiccil Salvage in Pulmonary Tuberculosis TABLE 1. OPERATIVE SALVAGE IN PULMONARY TUBERCULOSIS Patient Status Resection Decortication Thoracoplasty Total No. of patients Postop. deaths (< 1 mo.) 5 (9.1%) 1(1*8%) 1 (2.7%) 7 (43%) Early deaths (< 1 yr.) 5 (2 TB)" 0 3 (1 TB)" 8 (3 TB)" Late deaths (> 1 yr.) 17 (6 TB)' 2 (0 TB) 11 (0 TB) 30 (6 TB)' Alive &well(> 1 yr.) 1 4;l Lost subsequently 4 (50.9%) (94.4%) 2J (59.5%) (69.2%) Followed to date 24 "Tuberculosis (TB) was uncontrolled in 6.20/, (9 of 146 patients). these 54 patients (9497,) remained alive and well following operation, and 30 continue to do well after 10 years of postoperative follow-up. When resection and decortication are not feasible, a tailored thoracoplasty is used to solve the problem of a rigid, chronically infected pleural space. The space was successfully eradicated in all but 1 patient; in this patient secondary hemorrhage developed in the residual infected space. Similar results in 9 patients treated prior to 1953 (when protective chemotherapeutic coverage was not available) indicate the safety and applicability of this maneuver. Mortality and Survival In the entire series of 146 patients, the tuberculosis problem was controlled in all but 9 (94y0) and slightly more than 2 of every 3 patients returned to a normal, productive daily life with long-term survival (see Table 1). This outcome was unaffected by age or sex, though it did reflect the slight preponderance of male patients (60y0). Death was in nearly every instance the result of cardiorespiratory complications or uncontrolled tuberculosis, whether it occurred postoperatively, in patients who never recovered sufficiently to leave the hospital, or in those who were at home. This observation reflects the salvage nature of the procedures reviewed in this study. Predictably, postoperative mortality (4.8oj7,) occurred primarily in those patients undergoing resection, although only 1 death (bronchopleural fistula with empyema) could be related specifically to a technical complication. A death from septicemia was due to superimposed infection; a death from decerebrate rigidity was probably the result of extensive laceration of the lung during a tedious and difficult visceral decortication when it was assumed that air embolism had occurred. Additionally, there were 3 deaths from myocardial failure and 1 from lower respiratory infection. In those who died while still hospitalized the same general observations pertain. One patient succumbed to postpneumonectomy empyema and another to infection following exposure of the tracheobronchial tree during a tracheostomy. Uncontrolled tuberculosis (3), chronic nephritis (l), VOL. 18, NO. 1, JULY,

3 DELARUE AND GALE and ruptured abdominal aneurysm (1) accounted for the remaining 6 early deaths. An identical picture was apparent for those who died more than a year after treatment and after initial recovery had permitted hospital discharge. Deaths following resection totalled 17; thoracoplasty, 11 ; and decortication, 2; however, only 4 deaths resulted from factors unrelated to the salvage nature of the procedure. It is important to recognize the longevity that the salvage procedure gained for the patient. Twelve patients survived for 1 to 5 years, and 18 lived for periods ranging from 6 to 23 years. Although their life style was colored in many instances by the limitations imposed on them by their disease or the associated cardiorespiratory complaints, the majority were able to play a productive role in their family and community. This type of salvage was considered particularly fruitful since by far the greatest number of patients treated by the preferred procedures of resection or decortication (87 of 109 patients [SO yo]) were between 20 and 49 years of age, when family and community responsibilities are most important. In the thoracoplasty series there was a preponderance of older patients (indicating the chronicity of long-standing disease) which made it impractical to consider the more attractive procedures. Nonetheless, productive participation in daily activities was restored in 60% of the patients aged 50 to 69. Sa lunge Resection In an earlier report of the results achieved in treating tuberculous disease by resection 171, the incidence of major complications (spread of tuberculosis, bronchopleural fistula, empyema) was found to be 8.1% in 444 patients who had received adequate chemotherapy preoperatively. In this group, bronchopleural fistulas occurred in 5.9% (26 of 444 patients), and subsequent relapse of disease occurred in S.8YO (17 of the 444). The operative mortality was 1.6%. A favorable comparison could be made with those who had received inadequate chemotherapy preoperatively. The above figures represent a standard against which the achievements of salvage procedures can be assessed. In a further study [S], experience with salvage resection during the 10- year period between 1955 and 1962 was reviewed. At that time, 8% of all resections for tuberculosis at the Toronto Hospital were considered to be of a salvage type since all other therapeutic measures had failed to control the disease and other features had combined to make the patients poor operative risks. The results were considered so encouraging-successful rehabilitation in 65YO of patients-that additional patients were subsequently treated by resection. However, as predicted in the initial paper [7], suitable patients became less frequent with the increasingly effective use of drugs. The original series of 45 patients [S] has now been updated by including 12 patients seen in the following 10-year period. All 55 patients 40 THE ANNALS OF THORACIC SURGERY

4 TA1)I.E 2. SALVAGE RESECTION IN PULMONARY TUBERCULOSIS*- INDICATIONS IN 55 PATIENTS Indication No. of Patients Chemotherapy Failure Persisting cavity 47 Positive sputum 44 Positive empyema aspirate 2 Resistant organisms 36 Surgical Failure (28) Pneumothorax 9 Tlioracoplasty 8 Pneumothorax & tlioracoplasty 4 Resection 2 Pneumothorax & resection 1 Resection 8e thoracoplasty 4 'Pneumonectomy, 29; lobectomy, 20; segmental resection, 6. were treatment failures-primarily chemotherapy failures, since drug treatment had also failed to control disease that had remained active after previous operative treatment. The accepted indications for salvage resection are presented in Table 2. It also should be noted that serious impairment of respiratory function was present in more than half of the patients (29 of 55 [53y0]). These instances substantiated the salvage nature of the procedure. The incidence of postoperative complications was appreciable, as might have been anticipated (27 of 55 patients [490/1,]) (Table 3). Resistant organisms were present in 2 of every 3 patients (36 of 55 patients [65.4%]) and a persistent cavity in 47 of the 55 patients (85y0). In the 7 patients whose disease spread, 5 harbored resistant organisms: 3 of them subsequently died of tuberculosis. Postoperative mortality was only 9yo, and tuberculous infection was controlled in 47 patients (85y0). In addition, successful long-term rehabilitation was achieved in 28 patients (51%) (see Table 1). Technically the main problem was the occurrence of bronchopleural fistula, which became still more serious when prompt obliteration of the TABLE 3. SALVAGE RESECTION IN PULMONARY TUBERCULOSIS- POSTOPERATIVE COMPLICATIONS IN 27 PATIENTS Complication Bronchopleural fistula Empyema Spread of tuberculosis Pulmonary insufficiency (tracheostomy required) Myocardial insufficiency Atelectasis (bronchoscopic aspiration) Hemothorax Wound infection Psychosis No. of Patients VOL. 18, NO. 1, JULY,

5 DELARUE AND GALE TABLE 4. SALVAGE RESECTION IN PULMONARY TUBERCLJLOSIS- END RESULT OF POSTOPERATIVE BRONCHOPLEURAL FISTULA IN 11 PATIENTS No. of Patients Management Alive Dead Cause of Death No definitive therapy Spontaneous closure (1) 1 Spread of tuberculosis (2) 2 Tuberculosis Thoracoplasty (3) 1 2 Tuberculosis (8 yr.) Cor pulmonale (14 yr.) Drainage of empyema (5) 1 4 Tuberculosis (3 yr.) Pyogenic infection (1 mo., 2 mo., 1 yr.) Total (11) 3 8 (72.7%) pleural space was not achieved by expansion of the remaining lung. The catastrophic nature of a postoperative bronchopleural fistula in this type of patient is clearly defined in the high percentage of deaths which followed its development (8 of 11 patients [72.7y0]). In only 1 instance was the fatal outcome unrelated to the fistula or uncontrolled tuberculous disease (Table 4). Adequate expansion may be imperiled because the remaining lung is fibrotic and incapable of expansion or because too much lung is removed in the first place and the residual remnant simply cannot distend sufficiently, no matter how compliant it may be. For example, of 8 patients treated between 1952 and 1962 by left upper lobectomy plus apical segmental resection of the left lower lobe, 5 developed bronchopleural fistulas with empyema, 1 had a significant hemothorax (more than 1,000 ml.), and only 2 were free of complications. In this type of patient, therefore, the expansion capability of the remaining lung must be assessed. If it is reasonably suspect, the thoracic cage must be tailored to fit the lung rather than trying to force the lung to fill a space that it is quite incapable of obliterating. Pleural tents are rarely if ever practical in these resections because extra pleural dissection is so frequently required. Phrenic crush with pneumoperitoneum is well tolerated and particularly effective in lower lobe resections. The predictability of diaphragmatic recovery is suspect, however. Diaphragmatic reimplantation at a higher level is technically simple to accomplish, but the diaphragm loses its dome and diaphragmatic function is therefore seriously impaired. As an alternative the osteoplastic thoracoplasty described by Bjork [24] is attractive because of its simplicity and the immediate control of paradox. It is not unduly time-consuming, the first rib can usually be retained, and the deformity is not obvious. No space problem has been encountered in patients in whom it has been utilized. It is the treatment of choice in most instances. By ensuring rapid and complete obliteration of the pleural space, not 42 THE ANNALS OF THORACIC SURGERY

6 Surgical Salvage in Pulmonary Tuberculosis only does one decrease the risk of bronchopleural fistula or empyema, but maximum pulmonary function is retained because pleural reaction is minimized when pleural coaptation occurs before significant scar can develop. Sa 1 uage Decor t i cat ion The use of decortication at the Toronto Hospital has been reported previously [9, 101. In these earlier reports all patients having decortication were included, and at the present time 119 operations of this type have been performed. This review, however, surveys only those 54 patients in whom the maneuver fulfilled the requirements of a salvage procedure (see Table 1). In this sense it was used to control persistent pleural disease and relieve disabling complaints related to contracting fibrothorax or inexpandable lung following therapeutic compression (Table 5). The accepted operative techniques need not be reviewed, although it might be noted that complete expansion followed decortication in 3 patients in whom the lung had been compressed by an otherwise uncomplicated pneumothorax for over 20 years. Five complications, all controlled without a fatality, were encountered postoperatively: an incomplete expansion of lung, handled by thoracoplasty; a clotted hemothorax, solved by eventual resorption; an empyema, handled by thoracoplasty; a wound infection of nontuberculous bacteremia origin; and an acute surgical emphysema requiring collar needle aspiration. In the patient who developed rapidly increasing mediastinal emphysema with alarming and extensive subcutaneous emphysema of the head, neck, and upper trunk, the intercostal tube had been removed before the postoperative air leak had stopped. Control was achieved immediately by suction applied to a ring of subcutaneous needles placed in the lower cervical area. In 2 patients, however, an infected space persisted, and thoracoplasty was required to complete its obliteration. Obviously the type of decortication used in these patients was inadequate. Decortication is designed to encourage obliteration of the pleural space by allowing expansion of the previously entrapped lung. In entrapment of short duration, release of the lung will usually accomplish this purpose. In chronic cases, and particularly with persistent, albeit grumbling, infection, TABLE 5. SALVAGE DECORTICATION IN PULMONARY TUBERCULOSIS- INDICATIONS IN 54 PATIENTS Indication Tuberculous empyema Chronic pleurisy with fibrothorax Inexpandable lung Artificial pneumothorax Oleothorax No. of Patients VOL. 18, NO. 1, JULY,

7 DELARUE AND GALE parenchymal fibrosis associated with the inevitable disease in the underlying lung may limit expansion, and the enormously thickened parietal pleural surface, which is rigid and inflexible, may prevent accommodation by the chest wall. In these instances a parietal decortication is also required; and since the possibility of postoperative infection is an ever-present one when tissue planes are opened in this fashion, enucleation of the empyema would seem logical if both visceral and parietal pleural thickenings are to be excised anyway. Increasing experience with enucleation has indicated its feasibility and lack of postoperative complications. Current techniques [ 18, 201 involve blunt dissection in the extrapleural plane (which must frequently be forceful) until the palpable folds are reached at which the visceral and parietal thickenings meet at the margins of the empyema. Visceral decortication then begins beyond these folds. Sharp dissection is essential in separating basal empyemas from the diaphragm, and in these cases the thoracotomy incision should be placed at a lower level than is customary. The entire lung should be released in order to permit unimpeded and uniform reexpansion of the freed lung and ensure that all areas of the pleural space are obliterated. No complications have developed postoperatively. Successful rehabilitation was achieved in 52 patients (94%) (see Table l), indicating the value of this technical maneuver in advanced cases, no matter how tedious and difficult the operation may seem at the time. Salvage T horaco plasty When the pleural space cannot be obliterated by expansion of the lung because successful decortication is not technically possible, thoracoplasty is required (Table 6). In chronically infected spaces with rigid walls, the tailored thoracoplasty has become the procedure of choice both at the Toronto Hospital and at the Toronto General Hospital. The tailored operation has been performed 34 times and an osteoplastic thoracoplasty 3 times. On the Thoracic Surgical Service at these hospitals, interest in this maneuver dates back to the late 1930s. In 1953 Kergin [16] reported for TABLE 6. SALVAGE THORACOPLASTY IN PULMONARY TUBERCULOSIS- INDICATIONS IN 57 PATIENTS Indication No. of Patients Postresection empyema (bronchopleural fistula, 10) 16 Postpneumothorax complications Tuberculous empyema 6 Inexpandable lung (sterile effusion) 4 Postoleothorax complications Tuberculous empyema with bronchopleural fistulaa 1 Postaspiration pyogenic empyema 2 Primary tuberculous empyema 8 abronchopleural fistula was present in 11 patients. 44 THE ANNALS OF THORACIC SURGERY

8 Surgical Salvage in Pulmonary Tuberculosis Shenstone and Janes on a 15-year experience with the type of procedure we have come to call the tailored thoracoplasty. Originally, similar techniques were reported by Heller [14] in 1934 and Wangensteen [22] in 1935; Grow [13] described an identical operation in The operation is performed as follows. An exploratory rib resection is used for entry over the midpart of the rigid space; the overlying ribs are then resected just beyond the margins of the space. The intercostal bundles are raised from the thickened parietal wall, which is excised to unroof the entire cavity. The relaxed bundles will then fall against the visceral wall of the space; this wall is not disturbed unless extensive granulations require curettage or calcified plaques must be removed. If necessary these bundles can be sutured over bronchial fistulas or leaks from the surface of the underlying lung. In addition they are used to fill crevices which extend beyond the limits of rib resection, as for example in the paravertebral gutter or medial to the first rib, which is better left in place. Suction drainage is used postoperatively for an appropriate period. There are several advantages to the salvage operation as presently performed. Paradoxical movement is not a problem since the chronicity of the visceral or mediastinal reaction ensures stability. The intercostal nerves are preserved, and abdominal wall problems do not develop. The viable tissue collapses against the visceral or mediastinal wall to expedite healing and firm obliteration of the space. Crevices can be filled and fistulas can be covered directly. For use in tuberculous disease, the indications are primarily those related to chronic empyemas whether they follow resection or pulmonary compression (Table 6). Thirty-three of the 37 patients undergoing thoracoplasty fell into this group. Fistulas are also commonly encountered. In this group there were 11 bronchopleural fistulas, 10 of which followed previous resection of a nonsalvage type. The remaining fistula was associated with invasive aspergillosis (see Table 6). Nine patients suffered postoperative complications: 5 had wound infections, 3 had persisting bronchopleural fistulas, and 1 had spread of his tuberculosis. However, the complications which colored the postoperative course were not overwhelming except in 1 patient who died of uncontrolled tuberculosis while still in the hospital. Successful rehabilitation with longterm survival has been accomplished in 60% of the patients (see Table 1). Wound infections, whether tuberculous or pyogenic, resolved completely. Two of the 3 persisting bronchopleural fistulas closed spontaneously. The third patient died of staphylococcal septicemia associated with delirium tremens. Management of Bronchopleural Fistula The development of a bronchopleural fistula, with inevitable infection of the pleural space, creates a potentially life-endangering situation whether VOL. 18, NO. 1, JULY,

9 DELARUE AND GALE it occurs as an acute catastrophe or persists as a chronic, debilitating complication. It is therefore imperative that means of guaranteeing effective closure be available and be utilized successfully. The problem is particularly prevalent, as has been so clearly illustrated in the previously described experiences, in the type of patient who requires the salvage procedures being discussed in this paper. Interest in this problem was first generated on the Thoracic Surgical Service at the Toronto General Hospital when lung abscesses were treated by open drainage and fistulas commonly persisted after control of the infection. The value of vascularized, pedicled muscle flaps in expediting the healing of a great variety of fistulas has long been recognized [6, 15, 191. Wangensteen [23] indicated Kanavel s interest in these flaps prior to 1920, and Garlock [12] reported that as early as Abrasanhoff had used them in closing bronchopleural fistulas. Maier [I71 in 1949 recorded a series in which Berry s technique for using the pectoralis major muscle had been followed; Barker and colleagues [ 13 have recently recalled this procedure. In chest disease the latissimus dorsi muscle has usually been divided by prior thoracotomy. The pectoralis major, although available, requires an extension of the exposure, and the subscapular and teres major muscles can be used only after considerable additional dissection. Shenstone [21] was intrigued by the common availability of the intercostal bundle and in 1936 reported using it in patients with bronchopleural fistula. Since then, increasing utilization has led to assurance regarding its applicability and the predictability of the results achieved. As with the tailored thoracoplasty, use of the intercostal bundle has become, for us, the treatment of choice when viable grafts are required. Demos and Timmes [5] have described their technique in a recent paper. The technique has been simplified (Fig. 1). Usually the bundle, if divided, is based on the posterior pedicle since the blood supply seems more secure. When closing major bronchial fistulas, those of short duration are managed by reclosure of the stump over which the bundle is secured, usually by using the bronchial closure sutures and then covering the stump in tentlike fashion with marginal sutures through the bundle attaching it to the peribronchial tissue (Fig. 2). For chronic fistula the same basic procedure is followed, although the scar along the stump may need to be incised to mobilize a short segment of the bronchus. Reamputation is not attempted. The scar attached to the bronchial wall is used to strengthen the initial bronchial closure, and when suturing the bundle to the surrounding tissue, the line of scar division provides convenient and efficient anchoring points (Fig. 3). If there are multiple leaks from the surface of the lung-which may have a sievelike appearance-several bundles, usually undivided, can be sutured to the thickened pleura in a lacelike network to cover all the individual openings. They become rapidly adherent with secure closure of the leaks. 46 THE ANNALS OF THORACIC SURGERY

10 Surgical Salvage in Pulmonary Tuberculosis FIG. 1. Closure of bronchopleural flstula with intercostal muscle graft. The success achieved in treating 11 fistulas preoperatively in this fashion would seem to warrant wider utilization of the technique for both therapeutic and prophylactic purposes. In only 1 instance was a secure seal not accomplished, and in this case the patient succumbed very quickly to a staphylococcal septicemia associated with delirium tremens before final control might have occurred. The high incidence of fistula following critical salvage resections (1 1 of 55 patients [20%]) suggests that additional precautions should be taken to avoid a complication having such catastrophic implications. Keeping in mind the availability and effectiveness of intercostal muscle grafts, prophylactic use of this maneuver ought to be considered more seriously FIG. 2. Suture technique for interc :ostal muscle graft (early case). \ 8/ 3 VOL. 18, NO. 1, JULY,

11 DELAKUE AND GALE I I FIG. 3. Suture technique for 1 I intercostal muscle graft (late I case). when dealing with patients with similar problems in the future. If this procedure is planned for preoperatively, thoracotomy should include rib resection, since one bundle adjacent to the incision can be used as the graft and the other utilized to secure the intercostal closure. Comment This appraisal of long-term results achieved in treating these difficult problems suggests that recollection of the technical maneuvers utilized is important, despite the fact that tuberculosis as a surgical problem is no longer prevalent and may well disappear almost completely from our operative experience. Indeed, the record of operative treatment of patients with pulmonary tuberculosis at the Toronto Hospital [11] clearly indicates that very few patients require operative intervention, even of the salvage type. Nonetheless, the lessons learned in developing and refining the technical procedures required for effective management of the challenging problems of tuberculosis-failure of treatment to arrest disease, threat to life-expectancy, or prevention of return to normal activity-should not be forgotten. Many of these operative techniques are, on occasion, equally applicable in nontuberculous disease, and recognition of their potential role in general thoracic surgical practice is warranted. 48 THE ANNALS OF THORACIC SURGERY

12 Surgical Saluage iri Pulmonary Tuberculosis A rise in incidence of other types of serious parenchymal infection and the increasing safety of thoracic surgery will surely lead to greater utilization of salvage procedures in this field. Unfortunately, this trend is occurring at a time when experience with the treatment of challenging tuberculous disease is disappearing from programs of surgical training. As a result, those accepting responsibility for this type of salvage may well have to rely on the advice of others in reaching appropriate therapeutic decisions. The present report indicates the type of dividends that may be anticipated. Bronchopleural fistula remains a problem regardless of the disease treated, and secure closure must be obtained. Postpneumonectomy fistula can be managed with intercostal grafts whether it is in the acute stage or associated with chronic pleural infection. Primary wound closure is possible in early cases when treatment is prompt; in late cases the bronchial closure remains secure in the presence of thoracostomy stomas so that irrigations are safe if eventual closure of the chest wall is proposed. Persistent space following extensive partial resection requires closure in many instances, particularly when infection has supervened. The thoracoplasty techniques devised for similar situations in tuberculosis are readily applicable in such cases. Since the major ccmplications encountered in salvage operations are those of infection in unobliterated spaces and bronchopleural fistula, the lessons learned from the management of these problems should be increasingly applied as prophylactic measures when complications can be anticipated. In this report, mortality and the incidence of postoperative complications have been balanced against the dividends that followed salvage procedures. Control of tuberculosis combined with very lengthy survival in those rehabilitated (101 of 146 patients [69%]) clearly shows that the value exceeds the risk in these critically ill patients. That true salvage has been accomplished is also indicated by the fact that more than half (56%) of those rehabilitated have remained alive and free of disease longer than 10 years following treatment. Although not included in the 101 patients who were completely rehabilitated, many of those who eventually died after surviving longer than 1 year were able to pursue productive lives during their remaining years. One can reasonably predict nothing less when similar salvage maneuvers are indicated in nontuberculous disease. References 1. Barker, W. L., Faber, L. P., Ostermiller, W. E., and Langston, H. T. Management of persistent bronchopleural fistulas. J. Thorac. Cardiovasc. Surg , Bjiirk, V. 0. Thoracoplasty, a new osteoplastic technique. J. Thorac. Surg. 28: 194, Bjork, V. 0. Simultaneous bilateral resection with a space-diminishing procedure for pulmonary tuberculosis. J. Thorac. Surg. 33:617, VOL. 18, NO. 1, JULY,

13 DELARUE AND GALE 4. Bjork, V. O., and Carlens, E. Kesection of one lobe and one segment with an osteoplastic thoracoplasty. J. Thorac. Cardiovasc. Surg. 38:209, Demos, N. J., and Timmes, J. J. Myoplasty for closure of tracheobronchial fistula. Ann. Thorac. Surg. 15:88, Eggers, 0. The treatment of bronchial fistula. Ann. Surg. 72:345, Gale, G. L., Coulthard, H. S., and Delarue, N. C. Resection in pulmonary tuberculosis with a special study on the influence of residual disease upon relapse. J. Thorar. Cardiovasc. Surg. 43:239, Gale, G. L., and Delarue, N. C. Salvage resections in patients with advanced pulmonary tuberculosis. Can. J. Surg. 8:267, Gale, G. L. Decortication in Tuberculosis. In Medical Papers (Proceedings of the 54th Annual Meeting of the Canadian Tuberculosis Association, 1954). Ottawa: Canadian Tuberculosis Association, Pp Gale, G. L., and Delarue, N. C. Decortication in pleural and pulmonary tuberculosis. Can. J. Surg. 5: 172, Gale, G. L., and Delarue, N. C. Surgical history of pulmonary tuberculosis: The rise and fall of various technical procedures. Can. J. Surg. 12:381, Garlock, J. H. The treatment of persistent bronchial fistula and chronic empyema. Mt. Sinai Hosfi. J. 3:105, Grow, J. B. Chronic pleural empyema. Dis. Chest 1226, Heller, E. Ueber Verhutung und Behandlung der Empyemresthohlen. Chirurg 6:3, Keller, W. L. The treatment of bronchial fistulas. I.A.M.A. 8:1006, Kergin, F. G. An operation for chronic pleural empyema. J. Thorac. Surg. 26: Maier, H. C., and Luomanen, R. K. 1. Pectoral myoplasty for closure ol residual empyema cavity and bronchial fistula. Surgery 25:621, Paulson, D. In discussion of P. C. Samson and T. H. Burford. Total pulmonary decortication..7. Thorac. Surg. 16: 148, Pool, E. H., and Garlock, J. H. A treatment of persistent bronchial fistulas. Ann. Surg. 90:213, Samson, P. C. Empyema thoracis. Ann. Thorac. Surg. 11:210, Shenstone, N. S. The use of intercostal muscle in the closure of bronchial fistulae. Ann. Surg. 104:560, Wangensteen, 0. H. The pedicled muscle flap in the closure of persistent bronchopleural fistula. I. Thorar. Surg. 5:27, Wangensteen, 0. H. In discussion of N. S. Shenstone. The use of intercostal muscle in the closure of bronchial fistulae. Ann. Surg. 104:560, Discussion DR. WALTER L. BARKER (Chicago, Ill.): Dr. Delarue and Dr. Gale have highlighted some of the problems encmmtered in the current management of pulmonary tuberculosis in The advent of chemotherapy has removed most if not all cases of minimal to moderately advanced disease from surgical consideration. Despite this, we assert that there are still elective targets and indications for operative management of pulmonary tuberculosis. Surgical targets include the open cavity, the filled cavity or nodular disease, bronchiectasis, and cornified, destroyed lungs. Surgical indications include moderate to far-advanced cases with definite targets, poor chemotherapy, or uncooperative patients. Additionally, atypical organisms or resistant microorganisms, pleural residuals, and cicatricial endobronchitis or bronchostenosis comprise surgical candidacy. At the former Chicago State Tuberculosis Sanitarium, more than 1,600 operative procedures for tuberculosis were carried out from 1953 to In the 50 THE ANNALS OF THORACIC SURGERY

14 Surgical Salvage in Pulmonary Tuberculosis past 5 to 10 years the bulk of these procedures involved extensive pleuroparenchymal residuals in patients satisfying the previously mentioned criteria. In truth, the so-called routine cases were actually salvage cases. The majority of the procedures were resections, including almost 100 pleuropneumonec tomies. The criteria of acceptance for operation and the principles of management for these far-advanced cases include bacteriological stabilization by stringent chemotherapeutic regimens, precise anatomical localization of specific residuals, detailed physiological assessment, and exact timing of operative intervention. If done so, the surgical procedures-be they resection, decortication, or thoracoplasty-can be accomplished with low morbidity and mortality, including only rare spread of the disease. With regard to decortication, we believe one should not put off simple and elective decortication today for complicated and salvage pleuropneumonectomy tomorrow. We think decortication should be done as primary surgical therapy for elective pleural residuals and that it can be accomplished with minimal morbidity and mortality together with excellent return of function, as the authors 94% successful rehabilitation for salvage cases would seem to indicate. The tailored thoracoplasty presented by the authors and previously described by Dr. Kergin is indeed a useful maneuver. We generally use this, however, for the nontuberculous, fixed pyogenic empyema space which has not been obliterated by drainage alone. We think, too, that performing thoracoplasty without venting the pyogenically infected space by adequate drainage is unwarranted. Pedicled muscle grafting for the management of persistent bronchopleural fistula is an old procedure upon which we have recently reported. We too have successfully closed an early postpneumonectomy mechanical disruption of the bronchus using a pedicled intercostal muscle graft. However, pedicled muscle grafting in the face of acute and active suppuration is usually doomed to failure. In closing, we believe that many procedures described by Dr. Gale as salvage operations might very well have been approached aggressively earlier with primary resection, decortication, or pleuropneumonectomy and, with stringent chemotherapeutic preparation, could have been accomplished with minimal mortality and morbidity. DR. GALE: I want to thank Dr. Barker for his discussion of our paper, which was of great interest. His series, of course, is considerably larger than ours in Toronto. Perhaps the only other comment I could make is that, having watched Margot Fonteyn dying of consumption in the arms of Rudolph Nureyev in the theater across the road here, it is nice to be able to report that there are still some cases of tuberculosis that we can salvage. VOL. 18, NO. 1, JULY,