CLINICAL REVIEW. The Surgical Treatment of. Pulmonary Tuberculosis. John D. Steele, M.D.

Transcription

1 CLINICAL REVIEW The Surgical Treatment of Pulmonary Tuberculosis John D. Steele, M.D. T his review is intended primarily for thoracic surgeons who have had their training in the present decade. It will attempt to outline the radical changes in the therapy of pulmonary tuberculosis which have taken place in the last 25 years. There are many reasons for these changes, the most important being the advent of effective antituberculosis chemotherapy and the refinement of surgical techniques, particularly that of pulmonary resection. Twenty-five years ago the prognosis of a patient with pulmonary tuberculosis was considerably enhanced if his disease presented an indication for surgical (or collapse) therapy. There is no doubt that many patients are living today because they had collapse therapy in one form or another in the prechemotherapy era. Although most collapse therapy procedures have been abandoned, some are still in use. The surgeon who is responsible for the treatment of patients with pulmonary tuberculosis today should at least be aware of the older procedures and what they had to offer. Not only are they of historical interest, but the lessons learned from some of them are still applicable to present-day treatment. The history of collapse therapy and of the use of pulmonary resection in tuberculosis [l, 31 is interesting but will not be covered in this review. The history of the discovery and initial testing of the antituberculosis drugs is also fascinating [Z]. Table 1 lists the procedures most commonly employed 25 years ago, those which are commonly in use today, and one which may be considered as a last resort. From the Veterans Administration Hospital, San Fernando, and the Department of Surgery, U.C.L.A. School of Medicine, Los Angeles, Calif. Address reprint requests to Veterans Administration Hospital, San Fernando, Calif THE ANNALS OF THORACIC SURGERY

2 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis TABLE 1. SURGERY AND COLLAPSE THERAPY IN THE TREATMENT OF PULMONARY TUBERCULOSIS Phrenic paralysis Pneumothorax Intrapleural pneumonolysis Pneumoperi toneum Thoracoplasty Cavernostom y Pulmonary resection Pulmonary resection Thoracoplas ty Standard Plombage Cavernostomy Bed rest was formerly the foundation for other methods of treatment, Good treatment consisted of bed rest for 24 hours a day at least during the first few months of treatment. Exercise was gradually increased if and when the pulmonary lesion began to come under control. Even under the most favorable circumstances, a year of sanatorium treatment was the rule. Collapse therapy was used in up to 70% of all sanatorium patients. Those who did not receive it had either very minimal lesions or bilateral destructive lesions which were too advanced to be considered for collapse. Actually the purpose of collapse therapy was relaxation of the disease, so as to allow the scar tissue produced by the natural healing process a better chance to contract. Streptomycin was produced in the laboratory in It was tested in guinea pigs in the same year, and limited clinical trials were started the next year. Isoniazid became available in Now chemotherapy is the foundation for the treatment of pulmonary tuberculosis and is definitive in from 90 to 95% of all cases; it is only when chemotherapy fails that surgical measures must be used. The procedures in both columns of Table 1 are listed more or less in the order of their simplicity and their safety. Twenty-five years ago pulmonary resection was a last-resort procedure carrying a high risk; today it is usually the first choice when surgical therapy becomes necessary. Only cavernostomy remains near the bottom of both lists. PHRENIC NERVE PARALYSIS The purpose of phrenic nerve paralysis in the treatment of pulmonary tuberculosis was to relax the lung and also to rest it. Following paralysis, a rise of the hemidiaphragm could be expected, thus reducing the distance from the apex of the lung to the base and relaxing the diseased portion. Since the excursion of the diaphragm on the paralyzed VOL. 6, NO. 5, NOV.,

3 STEELE FIG. 1. Anatomical relationships of the phrenic nerve, scalene mtiscles, and brachial plexus. Accessory phrenic trunk is seen arising from the fifth i.oot of the brachial plexus. At top, the routine incision for a phwnic crush. Position of head is important during dissection. (Modified from Alexander [I]. Reprinted by permission of Charles C Thomas.) 486 THE ANNALS OF THORACIC SURGERY

4 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis side ceased, the lung received more rest. Rest of the lung was considered desirable, just as bed rest lowered the respiratory rate and so rested the lung. The anatomy of the phrenic nerve in the neck is shown in Figure 1. Anatomical variations are frequent, but normally the nerve arises from the third, fourth, and fifth roots of the cervical plexus and lies on the anterior surface of the anterior scalene muscle running mesially to enter the mediastinum beneath the subclavian vein. In a majority of instances an accessory phrenic trunk arises from the fifth root of the brachial plexus and joins the phrenic nerve in the mediastinurn. When phrenic nerve paralyses were first performed, the nerve was cut in the neck and evulsed by twisting it around a hemostat, which had a guard on it to prevent it from slipping off the end (Fig. 2A). This, of course, produced a permanent paralysis. Accessory phrenic trunks were not a problem, since they were evulsed with the main trunk. It became apparent that permanent phrenic nerve paralyses were not always desirable. Furthermore, these phrenic exereses, as might be expected, were complicated occasionally by bleeding into the mediastinum. To overcome these disadvantages, temporary phrenic nerve paralyses were universally performed, beginning about The phrenic nerve was crushed as it crossed the anterior scalene muscle in the neck, and accessory trunks were resected. Crushing of the phrenic nerve produced diaphragmatic paralysis lasting from 6 to 8 months, although a small percentage became permanent. If an accessory trunk was not resected, it could take over the function of the phrenic nerve within a few months. It was thought that crushing the nerve at one point only for a A B FIG. 2. (A) Hemostat with guard at tip used for euulsion of phrenic nerve. (B) Haight phrenic nerve crusher with +idge designed for crushing very nuvow segment of nerve. VOI.. 6, NO. 5, NOV.,

5 STEELE very short distance would lower the incidence of permanent paralyses. A special instrument was devised for this purpose (Fig. 2B). If the progress of healing of the tuberculous process was favorable, further periods of temporary paralysis could be produced by recrushing the nerve, which usually could be found without too much difficulty in spite of scar tissue resulting from the initial or a secondary procedure. How much good phrenic nerve paralyses did is difficult to evaluate in retrospect, although many enthusiastic reports appeared at the time. Cavities in the base of the lung may have responded more favorably than others; possibly there was some effect on apical and midlung disease. Controlled studies in the field of medicine and surgery randomizing patients were unknown until later. Healing of the tuberculosis after a phrenic nerve paralysis had been performed (Fig. 3) naturally was encouraging. Actually, phrenic nerve paralyses probably did relatively little harm, although ventilation and the ability to cough was reduced. Bilateral phrenic nerve paralyses could even be tolerated without difficulty. In the 1930 s many thousands of phrenic nerve paralyses were performed, the operation,being more popular in certain geographical areas of the United States than in others. In some sanatoria when a patient was admitted with minimal or moderately advanced bilateral disease, the only question to be answered was on which side the phrenic nerve paralysis should be performed. A FIG. 3. (A) Young woman admitted with moderately advanced exudative pulmonary tuberculosis of right upper lobe in September, (B) Marked clearing of disease in April, 1935, following temporary phrenic crushing which produced paralysis and good rise of right hemidiaphragm. B 488 THE ANNALS OF THORACIC SURGERY

6 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis PNEUMOTHORAX The use of induced pneumothorax in the treatment of pulmonary tuberculosis began in the late nineteenth century and came into wide use between 1920 and It was still used to some extent until about To induce a pneumothorax, a needle was introduced into the pleural cavity. When negative pressures and fluctuations were obtained on a water manometer, several hundred cubic centimeters of air were induced slowly, while the pressures were taken frequently to make sure that a small pleural pocket had not been entered. A standard pneumothorax apparatus is shown in Figure 4. Air was introduced by raising the bottle on the right, which was filled with fluid. As the water flowed into the lower bottle, a measured amount of air entered the patient s pleural cavity. By turning the stopcock the flow of air could be stopped and the pressures measured. Several days later another refill was given, and frequent refills were continued until the desired amount of collapse (relaxation) was obtained. Thereafter, refills maintained this collapse, the refill intervals depending on how rapidly each patient absorbed air (actually, the oxygen was absorbed in 24 hours). Once a pneumothorax was established, refill intervals usually averaged a week or ten days. The patient was carefully fluoroscoped prior to each refill by the physician who was giving the refills. FIG. 4. Standard pneumothorax apparatus. By filling bottle on right with fluid and raising bottle, a measured amount of air can be introduced into pleural cavity; by reversing elevation of bottles, air can be withdrawn. Zntrapleural pressures can be taken with water manometer at left. VOL. 6, NO. 5, NOV.,

7 STEELE If there were no interpleural adhesions and a good relaxation of the lung was obtained, the pneumothorax relaxed the lung effectively. Contraction of scar tissue was promoted, and cavity walls could approximate. The collapse interfered surprisingly little with pulmonary function, even when bilateral pneumothorax was used. Of course, most patients with pulmonary tuberculosis in that era were relatively young. Once a satisfactory collapse by pneumothorax had been obtained, the question always arose as to how long to continue it. As a rule, two years was a minimum and many were continued longer, usually on an ambulatory basis. When refills were discontinued, the lung reexpanded and the undiseased portions of the lung overinflated to compensate for the contracted disease portions. Thus, if all went well, pneumothorax was an excellent procedure. However, only in a relatively small percentage of all patients with pulmonary tuberculosis could pneumothorax be induced and a good initial collapse of the lung be obtained and carried to a successful conclusion. In many cases, pleural adhesions prevented the induction of pneumothorax; in others, pleural adhesions might stretch so that it was possible to divide them surgically (see Intrapleural Pneumonolysis, below) and convert an unsatisfactory collapse into a satisfactory one. Another problem was the formation of fluid in the pleural cavity. This was practically always due to tuberculous infection. The character of the fluid varied from thin and serous to thick, tuberculous pus. Most patients with pneumothorax had fluid of varying amounts at one time or another during the course of their treatment. If fluid persisted, a thick peel formed over the lung, holding it captive. This could, of course, be removed by decortication, but decortication was not developed until the mid-1940 s. If the fluid became thick pus, frequent aspirations sometimes were effective, but there was always the danger of tuberculous needle-track infection. Extensive thoracoplasties were often necessary for the obliteration of tuberculous empyemas complicating pneumothorax. Intrapleural Pneumonolysis. When, after the establishment of a pneumothorax, adhesions which had stretched out to a fairly good length but which prevented a satisfactory collapse could sometimes be divided surgically (Fig. 5). This could be done by performing an open thoracotomy or by the closed method using a thoracoscope (Fig. 6). The closed method was widely used and preferred. Under local anesthesia two cannulas usually were inserted into the pleural cavity. Through one the thoracoscope (having either a fore-oblique or a right-angle lens) was inserted; through the second a cautery was inserted. It was important, of course, to be sure that fibrous tissue only was divided. Thick adhesions could contain lung tissue or even an extension of a cavity, 490 THE ANNALS OF THORACIC SURGERY

8 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis AIR IN PLEURAL FIG. 5. Diagram showing interpleural adhesions preventing satisfactory collapse of right lung by induced pneumothorax. These adhesions are of good length and are of the type suitable for division by intrapleural pneumonolysis. K -.&- FIG. 6. Thoracoscope with right-angle lens. Various types of cannulas, cauteries, and cazitery sheaths are shown, as well as a biopsv forceps. (Courtesy Pilling Company.)

9 STEELE and division would result in a bronchopleural fistula and empyema. The safety of intrapleural pneumonolysis depended largely on the judgment of the surgeon. Sometimes, if all adhesions could not be divided, the remaining adhesions might be divided at a second stage after stretching for a few weeks. On the other hand, if adhesions appeared to be too thick for safe division, it was far better to abandon the pneumothorax and rely on some other collapse therapy procedure. PNEUMOPERITONEUM Pneumoperitoneum could be induced and maintained in a manner similar to pneumothorax. With pneumoperitoneum both hemidiaphragms were elevated to some extent (Fig. 7). Results of the procedure alone were difficult to evaluate, and now it seems that any favorable results could possibly have been attributed to ather factors. To be sure, the addition of a pneumoperitoneum to a phrenic paralysis would produce a rise of the hemidiaphragm sometimes twice as great as could be obtained with the phrenic paralysis alone. The combined procedures were sometimes effective in the closure of basal cavities and could even be considered today when no other procedure is available. FIG. 7. Both sides of diaphragm are elevated slightly by pneumoperitoneum, which has displaced abdominal viscera (asymptomatically). 492 THE ANNALS OF THORACIC SURGERY

10 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis EXTRAPLEURAL PNEUMONOLYSIS When dense interpleural adhesions prevented the induction of a pneumothorax and when the use of thoracoplasty did not seem to be applicable or desirable, an extrapleural pneumonolysis might be performed. A small piece of rib was resected, usually with local anesthesia, between the scapula and the spine. The parietal pleura was exposed and dissected away from the chest wall by blunt dissection. Thus a space was created between the apex of the lung, covered by both visceral and parietal pleura, and the chest wall. The space thus created had to be filled with some material in order to maintain the collapse (relaxation) of the lung so produced. The most common methods of maintaining the space were to fill it with lumps of paraffin or to maintain the extrapleural pneumothorax which had been produced. Embedding paraffin with a melting point of 52 C. was used as a plombe. This eventually became encapsulated with scar tissue and remained in place indefinitely if all went well (Fig. 8). Actually this was a rather successful method of controlling relatively small apical lesions. The greatest drawback to the use of extrapleural pneumonolysis was that certain chronic tuberculous cavities obtained some of their blood supply from the chest wall, and when they were separated from the chest wall, the peripheral portion of the cavity might slough. If paraffin had been introduced, the first indication of this was that the patient expectorated slivers of paraffin. Treatment of this complication, as might be imagined, was complicated and not always satisfactory. Fortunately, this complication was fairly infrequent. The other method of holding the collapse after an extrapleural pneumonolysis was keeping up air refills, in which case the procedure was known as extrapleural pneumothorax (Fig. 9). A more extensive collapse could be produced by extrapleural pneumothorax than with paraffin. There was always a tendency for the space to obliterate due to pleuritis. For this reason it was necessary to introduce air under positive pressure, often up to 50 cm. H,O. Tuberculous empyemas in the extrapleural space were not uncommon. Sometimes the air in an extrapleural pneumothorax space was replaced with sterile mineral oil, thus creating an oleothorax. (Oleothorax was occasionally used also with intrapleural pneumothorax.) The oil became encapsulated by a thickened fibrous capsule. It was necessary to insert a needle into the oil space occasionally to make sure that the pressure had not risen beyond atmospheric levels. Rising pressure, often due to fluid within the space, might produce a bronchopleural fistula, in which case the oil might be aspirated into portions of both lungs with unfortunate results. VOL. 6, NO. 5, NOV.,

11 STEELE A B FIG. 8. (A) Extrapleural pneumonolysis with parafin filling shown diagrammatically. (From Alexander [I]. Reprinted by permission of Charles C Thomas.) (B) Present x-ray appearance of successful extrapleural parafin filling performed 20 years ago. 494 THE ANNALS OF THORACIC SURGERY

12 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis FIG. 9. Bilateral extrapleural pneumothoraces in young woman who had no dyspnea even on exertion. STANDARD THORACOPLASTY (See Table 1.) In the early days of thoracoplasty too many ribs were resected at one operation with resulting paradoxical motion of the chest wall. This led to a high operative mortality. It was realized that the operation should be performed in multiple stages, which lowered the operative mortality to 1% or less. It also became apparent that the level of resected ribs posteriorly should correspond to the level anteriorly, thus producing a squared off thoracoplasty. Most surgeons also resect the transverse processes in order to produce the maximum collapse obtainable. The extent of the thoracoplasty will depend on the extent of the disease. An average thoracoplasty may consist of the resection of 7 ribs in three stages (Fig. lo), the entire first and second ribs being resected at the first stage together with a portion of the third. If no appreciable paradoxical motion of the chest wall is present at the time of operation, such a thoracoplasty may be done in two stages rather than three. However, dangerous paradoxical motion of the chest wall is extremely difficult, if not impossible, to treat and should be prevented. Thoracoplasty stages are performed at 2- to 3-week intervals. The ribs are, of course, resected subperiosteally, and regeneration starts fairly rapidly. For this reason the 3-week interval between stages should not be exceeded; otherwise, the stiffened chest wall will prevent a satisfactory collapse. VOL. 6, NO. 5, NOV.,

13 STEELE A B FIG. 10. (A) A typical 7-rib thomcoplasty peyfo?med in three stages shown diagrammatically. The transverse ~~oce.sses have been resected. The anterior jib stumps have been resected to the level of the remaining posterior ribs. (Modified from Alexander [l]. Reprinted by permission of Charles C Thomas.) (B) Pzthoracoplasty and (C) postthoracoplasty chest x-rays of 55-year-old man who had been admitted with far-advanced bilateral Pulmonary tuberculosis which had responded fairly well to antituberculosis chemotherapy except for residual cavitary disease on the left involving the upper lobe and superior segment of the lower lobe. Sputum remained positive for tubercle bacilli. Cavities closed and sputum converted by 7-rib thoracoplasty. C 4'36 THE ANNALS OF THORACIC SURGEKY

14 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis There is some deformity with thoracoplasty, but not as much as might be imagined. Because the clavicles hold the shoulder girdle in place, the shoulders should remain level (Fig. 11). It is sometimes necessary to resect a small portion of the scapula when it tends to become impinged beneath the last unresected rib. There is a tendency to scoliosis with thoracoplasty, the convexity of the curve being toward the thoracoplasty side. With proper physical therapy, scoliosis can be minimized and arm motion retained. When a patient is clothed the thoracoplasty should not be evident. Because it may be difficult or impossible to control scoliosis in young people, thoracoplasties are not usually advised in children and young adults. The results of thoracoplasty in the closure of tuberculous pulmonary cavities are good on the whole. In properly selected patients, cavity closure and sputum conversion can be expected in 80 to 90%. The use of thoracoplasty for the obliteration of tuberculous empyemas which occupy the entire hemithorax usually requires the resection of 9 or 10 ribs. When such an empyema is drained originally, it is well to anticipate the possibility of a subsequent thoracoplasty so that the point of drainage will be anterior to and below the thoracoplasty incision. Because there is no paradoxical motion of the chest wall with an empyema, the extrapleural portion of the thoracoplasty can usually be done in two stages, staying away from the draining sinus. The last stage will consist of a Schede stage, at which the rib stumps about the draining sinus are resected and the residual cavity unroofed by removing the thickened parietal pleura (and intercostal bundles) and allowing A B C FIG. 11. Photographs show relative lack of deformity following 8-rib thoracoplasty during which transverse processes were also resected. Patient cooperated well in carrying out prescribed postthoracoplasty physical therapy measures. VOL. 6, NO. 5, NOV.,

15 STEELE the soft tissues of the chest wall to fall in against the visceral pleura. Thoracoplasty is an effective method for the obliteration of tuberculous (and nontuberculous) empyemas. Alternative procedures may be pleuropneumonectomy or decortication. EXTRAPERIOSTEAL PLOMBAGE (PLOMBAGE THORACOPLASTY) During the 1940 s it was realized that an excellent collapse of the lung could be obtained by stripping the periosteum off the ribs and letting the lung, with parietal pleura, periosteal beds, and intercostal muscles and bundles, fall away from the chest wall. The advantage of this type of collapse over extrapleural pneumonolysis is that a more extensive collapse can be obtained, if desired, and any blood supply a tuberculous cavity may obtain from the intercostal circulation is not compromised. Substances used to maintain the collapse have included Lucite spheres (Fig. 12A, B), Ivalon sponges, Ping-Pong balls, polythene spheres and sheets, and paraffin (Fig. 12C). Of course, the spheres have to be large enough so that they will not slip between the denuded ribs, and paraffin has to be introduced in one mass which has been molded to fit the extraperiosteal space. The ribs can easily be spread for the introduction of these materials. The advantage of this procedure over a standard thoracoplasty is that much more collapse can be effected in a one-stage procedure. On the other hand, the collapse may not be as satisfactory as with standard thoracoplasty, especially for large or medially located cavities. Infection in the extraperiosteal space can occur, and migration of the introduced foreign bodies has been reported not infrequently. Pressure necrosis of various adjacent structures by Lucite spheres has sometimes produced rather dramatic complications. Experience with paraffin and polythene spheres has been rather good, better than with Lucite spheres or Ivalon sponges. For instance, if the paraffin mass migrates, it is a fairly simple operation to remove it and unroof the residual space by resecting the original ribs. By this time regeneration of ribs from the displaced periostea will have taken place and will maintain the collapse. Because of the possibility of infection or other complications, a few surgeons make it a practice to remove the plombe routinely after several months. Most others remove the plombe only if and when the plombage material migrates, which does not occur in more than 15% of the cases. Still others are inclined to remove the plombe electively in young patients only. 498 THE ANNALS OF THORACIC SURGERY

16 CLINICAL REVIEW: Surgery for Pu1monai.y Tuberculosis A B C FIG. 12. (A) Diagram of Lucite spheres in extraperiosteal space. These can be enclosed in polythene sheeting. (B) X-ray appearance following extraperiosteal Lucite plombage. (C) X-ray appearance following extraperiosteal parafin plombage. Cavities closed and sputum negative. Note the evidence of rib regeneration which has taken place from the displaced periosteal beds (beneath and mesial to the parafin). It was a distinct advantage in this psychotic patient to be able to control the tuberculosis with a one-stage operation,. Standard thoracoplasty would have required two or more stages. One disadvantage of an extraperiosteal plombage is that the subsequent pulmonary resection beneath it, when necessary, is often extremely difficult technically, more so than with standard thoracoplasty. An advantage of plombage thoracoplasty over standard thoracoplasty is that it apparently reduces pulmonary function less and thus may be applicable in patients who could not tolerate standard thoracoplasty or resection because of age, emphysema, or extensive disease. VOL. 6, NO. 5, NOV.,

17 STEELE PULMONARY RESECTION As indicated previously, pulmonary resection is the surgical procedure of choice when chemotherapy has failed to control the tuberculous process satisfactorily. The extent of the resection will depend on the extent of the disease. Before the role of chemotherapy in the treatment of pulmonary tuberculosis had become firmly established, many relatively small residual lesions were resected by segmental and subsegmental pulmonary resections. Now most resections are either lobectomies or pneumonectomies. The operative risks for various types of pulmonary resections for tuberculosis are given in Table 2. These have remained quite constant, even the operative mortality of pneumonectomy. In avoiding complications in lobectomy, it is important that one be reasonably sure that residual lobes have the capacity to expand to fill the pleural cavity. Emphysematous lobes and lobes which have been the seat of considerable previous disease are not good space fillers. For this reason a prior partial thoracoplasty to reduce the size of the hemithorax is sometimes advisable. Concomitant thoracoplasties sometimes can be done but are usually not as satisfactory as prior thoracoplasties. It is customary to cover the period of resection with antituberculosis drugs to which the patient s tubercle bacilli may still be sensitive. This may help to prevent spread of the tuberculosis following resection and diminish the possibility of complicating tuberculous empyema, although the value of such coverage is difficult to prove. Certainly the availability of additional drugs should not compromise sound surgical principles. The most important indication for surgery in pulmonary tuberculosis is an open cavity with sputum positive for tubercle bacilli. Indications for surgery in so-called open-negative cavities are often equivocal. In some centers these cavities are not considered as presenting an indication for resection. In others, open-negative cavities are resected in young patients and in those patients whose reliability as far as taking TABLE 2. SURGICAL MORTALITY, 6,261 PULMONARY RESECTIONS FOR PULMONARY TUBERCULOSIS, VETERANS ADMINISTRATION- ARMED FORCES HOSPITALS, JULY 1, 1952, TO JULY 1, 1957 No. of Procedure Operations Deaths Percent Pneumonectomy Lobectomy 2, Segmental 2, Subsegmental THE ANNALS OF THORACIC SURGERY

18 CLINICAL REVIEW: Surgery for Pulmonary Tuberculosis antituberculosis chemotherapy indefinitely may be open to question. Resection for closed fibrocaseous lesions is now rarely performed except under unusual circumstances. Surgery is more often indicated in disease caused by the atypical mycobacteria (M. Kansasii, etc.) than in that caused by M. tuberculosis, because the atypical organisms are much less likely to respond to antituberculosis chemotherapy. It is usually possible to ascertain within a few months after the start of treatment whether surgery will be necessary or whether chemotherapy will suffice. In spite of the lack of sensitivity of these organisms to effective drugs, the surgical complications in these cases are no greater than for cases with disease due to M. tuberculosis. The choice between resection and thoracoplasty (standard or plombage) often depends on the extent of the disease. When two lobes are involved, the difference in the operative mortality of thoracoplasty (approximately 1%) and pneumonectomy (10 to 1.5%) must be taken into consideration. It is also sometimes possible to start with a trial of thoracoplasty, evaluate the status of the collapse after each stage, and proceed to resection if it appears that thoracoplasty will not be effective. The use of pleuropneumonectomy in the treatment of tuberculous empyemas has been mentioned above. When a tuberculous empyema is present, often with a bronchopleural fistula, and the underlying lung cannot be expected to expand to fill the pleural cavity following decortication, then pleuropneumonectomy should be considered, the alternate procedure being a complete thoracoplasty. In a pleuropneumonectomy the empyema pocket is removed with the lung. Removal of the empyema pocket is often a tedious and difficult procedure, but by the time the hilus of the lung is reached, dissection is usually quite easy. Any draining sinus in the chest wall is closed, and the hemithorax is allowed to fill as with the usual pneumonectomy. As might be expected, the possibility of postoperative infection is always present. CA VERNOSTOMY As indicated in the introduction, external drainage of a cavity through the chest wall is a last-resort procedure. The procedure was popularized by Monaldi 30 years ago. Monaldi introduced a trocar and cannula into a cavity through the chest wall and, after inserting a catheter, applied suction. An open cavernostomy performed in two stages is a safer method. At the first stage, a rib resection is performed and a pack placed against the parietal pleura and left in place for a week or ten days. This assures VOL. 6, NO. 5, NOV.,

19 STEELE the production of pleural adhesions and prepares the soft tissues of the chest wall for the subsequent drainage. At the second stage the cavity is entered with a cautery and a large tube inserted. Suction is not necessary. The disadvantage of the procedure is, of course, that a tuberculous broncho-pleural-cutaneous fistula is produced. The sinus will drain for many months, if not indefinitely. Cavities so drained should be single and unilocular and should be adjacent to the chest wall. The results of cavernostomy, as might be expected, are not very good, certainly no better than 50%. Sometimes cavernostomy can be combined with thoracoplasty in the treatment of huge cavities if pneumonectomy is not feasible. Actually, very few cavernostomies are performed today. SUMMARY A review of the surgical treatment of pulmonary tuberculosis has been presented, comparing the measures used 25 years ago with those in use today. Even though pulmonary resection is the procedure of choice when surgery is indicated today, collapse therapy procedures such as standard and plombage thoracoplasty are sometimes useful. REFERENCES 1. Alexander, J. The Collapse Therapy of Pulmonary Tuberculosis. Springfield, Ill.: Thomas, Davey, W. N., and Barnwell, J. B. The Chemotherapy of Tuberculosis. In J. D. Steele (Ed.), The Surgical Management of Pulmonary Tuberculosis. Springfield, Ill.: Thomas, P Steele, J. D. (Ed.). The Surgical Management of Pulmonary Tuberculosis. Springfield, Ill.: Thomas, THE ANNALS OF THORACIC SURGERY