Section 6 Pneumonectomy

Abstract

Thirty-four surgical specimens of tuberculous lobes and lungs were studied in order to correlate the clinical indications for resection with the pathology. Although the indications for resection are not clear cut, certain statements can now be made that may aid the surgeon in the selection of suitable cases.The patient with tuberculosis has often been a chronic invalid with irreparable damage to his cardio-respiratory system. The advantages to be gained from the surgical procedure should be carefully weighed against the operative risk. With advancing age there is increasing morbidity and mortality, particularly from cardio-respiratory embarrassment. In addition to electrocardiograms and other clinical tests for evaluating cardiac reserve, estimations of ventilatory function and oxygen and carbon dioxide diffusion in the alveoli would be ideal particularly in those cases presenting contralateral pleural fixation, collapse, fibrosis or emphysema.With the increasing availability of streptomycin, it should be administered preoperatively as well as postoperatively to all patients undergoing tuberculous pulmonary surgery. Its use apparently decreases the incidence of spreads by reducing the total volume of sputum and the number of bacteria. In certain types of cases, particularly those with tension cavities, the use of streptomycin may release the check-valve mechanism by healing the endobronchial tuberculosis, thus making the cavities amenable to the various collapse measures. In this way, streptomycin may decrease some of the indications for resection. At the same time, the drug often converts poor risk cases into cases suitable for surgery. Two patients in this series with severe endobronchial tuberculosis of the stem bronchus were resected without complications after streptomycin therapy. Most of our cases in whom resection was justified presented varying degrees of endobronchial tuberculosis.The incidence of early postoperative spreads was 6.2 per cent (two cases out of 32). Of the 30 patients who were operated under epidural anesthesia, there was only one spread (3.3 per cent). We feel that the use of this anesthesia was also an important factor in reducing the incidence of spreads, as the patients were conscious and co-operative, being able to cough and expectorate throughout the operative procedure.The clinical indications for resection in this series were: 1.Bronchostenosis.2.Tuberculous bronchiectasis.3.Destroyed lung with cavitation.4.Lower lobe cavities.5.Thoracoplasty failures.Bronchostenosis, the end result of endobronchial tuberculosis, is a justifiable indication for resection. Bronchiectasis is almost always present distal to the stricture, usually with varying degrees of endobronchial tuberculosis. The healing of parenchymal tuberculous lesions usually results in bronchiectasis, varying in proportion to the extent of the parenchymal lesion. The resultant upper lobe bronchiectasis is usually non-specific and its mere presence without symptoms should not be an indication for surgery. When this pathology is present with positive sputum, careful search should be made for occult cavities or active infiltration. With upper lobe bronchiectasis plus cavitation, thoracoplasty probably should be tried first. Bronchiectasis in the lower lung fields is more apt to be complicated by endobronchial tuberculosis. In the absence of an active parenchymal focus but with positive sputum and evidence of bronchiectasis (condition frequently seen following adequate thoracoplasties) one may be justified in making a diagnosis of bronchiectasis with endobronchial tuberculosis. In cases presenting cavitation, massive atelectasis, fibrosis, and bronchiectasis with positive sputum (the so-called “destroyed lung”) resection is the method of choice. Resection is also the procedure of choice in chronic bronchopleural fistula with empyema. The bronchus leading to the fistula is usually ectatic with endobronchial tuberculosis. In one of our cases, thoracoplasty alone was not successful in closing the fistula. In two, the resection was performed for hemoptyses. As the source of bleeding was from ectatic bronchi, they were classified in the “tuberculous bronchiectasis” group.Lower lobe cavities are frequently complicated by endobronchial tuberculosis. With the introduction of streptomycin they may respond satisfactorily to collapse therapy. The two cases in this series did not receive streptomycin but the presenting pathology justified their removal. In residual cavities following thoracoplasties, there are several operative procedures that may be utilized, depending somewhat on the general condition and age of the patient. Resection is the most formidable of these procedures, but gives the most gratifying results. It is doubtful whether surgical resection even as a heroic measure is indicated in caseous-pneumonic disease. Although there were no tuberculomas in this series, these lesions should be resected as they often contain caseous material and are always a potential source of spread. Radiographically, they oftentimes cannot be distinguished from neoplasms.Future reports should state specifically the type of pathology found, particularly in those cases presenting bronchiectasis with or without endobronchial tuberculosis. Further studies may produce a uniform basis of classifying the indications and contraindications for resection in pulmonary tuberculosis, which may be further clarified by long and careful follow-up periods.