Extrapleural Pneumothorax: A Report of Experiences and Present Day Indications

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At the time of revival of extrapleural pneumothorax in the treatment of pulmonary tuberculosis, it was hoped that the operation would solve the therapeutic problem of many patients urgently needing collapse therapy in whom the establishment of intrapleural pneumothorax was impossible. It has been emphasized by all writers that the procedure necessary to carry out extrapleural pneumothorax entailed less operative shock and, therefore, carried a lower operative mortality than thoracoplasty. It has been pointed out that the immediate objective, cavity closure, could be reached without subjecting the patient to multiple stage operations. It was also hoped that re-expansion could be effected later, if a temporary form of collapse were desired. With such a picture painted for extrapleural pneumothorax, one could visualize a useful place for it on either extremity of the position held by thoracoplasty. On the one hand, extrapleural pneumothorax could be considered for those cases with insufficient disease to justify thoracoplasty, i.e., a substitution for intrapleural pneumothorax in the event of adherent pleura. On the other hand, extrapleural pneumothorax could be considered in an attempt to salvage certain patients with far-advanced disease when thoracoplasty was contra-indicated by age, too extensive distribution of disease, too ill a patient, or severe complications. However, at the present time, six years after the revival of extrapleural pneumothorax by Graff and Schmidt, its value is still seriously questioned. Indications have been difficult to define and reports on end results are conflicting. Proctor and Dolley, Jones and Skillen contend that many cases considered to be unsuitable for thoracoplasty can be successfully managed by extrapleural pneumothorax with early conversion to oleothorax. Churchill has warned, however, that the procedure is too dangerous to use in treating unstable disease, or in preparing a patient for thoracoplasty, if there is a reasonable chance that this end can be accomplished otherwise. Davidson and Fink reported a high percentage of failures and found complications the rule rather than the exception. They felt that the use of extrapleural pneumothorax should be greatly restricted. The purpose of this paper is to give a late report on a group of patients treated from one to two and one-half years previously, to present indications used then and now, ! and finally to point out what is considered a better disposition of certain cases formerly accepted for extrapleural pneumothorax. Matters of surgical technique and after-care will not be discussed. No significant alterations have been made in the technique described in a preliminary report by Tubbs and the author.