Current Aspects of Surgery for Pulmonary Tuberculosis

Abstract

An entire generation of thoracic surgeons received much of their training and were well-versed in the operative treatment of pulmonary tuberculosis. Chemotherapy has revolutionized this aspect of thoracic surgery, and operations for tuberculosis have markedly decreased. But pulmonary tuberculosis, though reduced in incidence, is still a widespread scourge, and it is vital for the thoracic surgeon to understand the role of operative treatment. This review brings up to date the role of the surgeon in the treatment of pulmonary tuberculosis. ive years ago the late Dr. John Steele [29], then editor of The Annals of Thoracic Surgery, reviewed the history of the operative treatment F of pulmonary tuberculosis, outlining the radical changes which had occurred in the preceding two decades because of the introduction of effective antimicrobial agents. The article remains timely. I t places in historical and scientific perspective the present-day operative treatment of what continues to be the greatest infectious disease killer of our times. A considerable volume of literature has since accumulated concerning the relative merits of resection and other forms of therapy, the indications for and results of operation, and proper handling of the complications which occur. The purpose of this review is to present the current surgical therapy for pulmonary tuberculosis in light of this increased experience. From the Division of Thoracic and Cardiovascular Surgcry, Univcrsity of Maryland School of Medicine, Baltimore, Md. The authors gratefully acknowledge the training and guidance of Drs. John E. Miller, Eugene Linberg, Elmer R. Sailer, and William Newcomer of the Mount Wilson State Hospital, Baltimore, and thank Dr. David G . Simpson, Professor of Medicine and Chief of the Division of Pulmonary Disease, University of Maryland Hospital, for his review of the manuscript. Address reprint rcqucsts to Dr. McI,aiighlin. Division of Thoracic and Cardiovascular Surgery, University of Maryland School of Medicine, Baltimore, Md. 21201. MC LAUGHLIN AND HANKINS Present Indications for Operative Treatment With the advent of adequate chemotherapeutic agents, the indications for surgical treatment of pulmonary tuberculosis were widely extended. Previously, operative treatment had been indicated only for those patients in whom collapse of a portion of the lung would be potentially beneficial or in whom some complication made operative intervention mandatory. Chemotherapy would stop the progression of the disease, heal tuberculous bronchitis, and bring about resolution of pneumonia while necrotic areas in the lung underwent fibrosis. Resection of residual foci of necrosis and fibrosis could then be performed safely. The literature of the 1950s and 1960s is replete with series of superb operative results” [l , 17, 19, 251. However, it became apparent that many patients who had undergone resection would have been cured whether or not resection had been carried out. For example, patients treated with chemotherapy and thoracoplasty, either conventional or of the modified plombage type, had a high cure rate: and, most importantly, patients whose sputums became bacteriologically negative and who for some reason or other were not operated upon despite residual cavitary disease often were cured” [8, 251. Considerable controversy existed over whether or not the patient with an “open negative” cavity should be operated upon, and it was not until studies based upon controlled series were completed that the proper course of action was placed on a scientific basis [8]. Recently the trend has been to operate on those patients in whom chemotherapy does not bring about a rapid halt in the progression of the disease or in whom social, economic, or other factors-including the presence of atypical mycobacterial disease-militate against the success of chemotherapy alone. Thus, patients with pulmonary tuberculosis who are operated on at the present time are a considerably different group of patients than those operated upon previously. Their disease may be active, other complicating factors often are present, and the incidence of complications has increased. Further, operation for tuberculosis and treatment of the complications of tuberculosis per se once again have become important aspects of the thoracic surgeon’s involvement in this disorder. The following are indications for surgical treatment of tuberculosis: 1. Active localized disease not responding to chemotherapy, including infection with atypical bacteria 2. Residual foci of disease in patients in whom social or medical indications of potential reactivation exist or foci which interfere with proper pulmonary function or toilet 3. The possibility of coexisting carcinoma 4. Various complications of pulmonary and pleural tuberculosis, in*Corpe, R. F., and Liang, J. Current concepts of indications of excisional therapy for pulmonary tuberculosis. Unpublished data, 1973. 514 THE ANNALS OF THORACIC SURGERY CURRENT REVIEW: Surgeiy for Pulmonary Tuberculosis cluding empyema, bronchopleural fistula, and massive hemorrhage from a cavitary lesion 5. Management of complications following resection for tuberculosis ACTIVE LOCALIZED DISEASE NOT RESPONDING