An Evaluation of 95 Consecutive Pulmonary Resections for Tuberculosis*

An

Evaluation

of

95 Consecutive

Resections

Tuberculosis*

J. SHABART, M.D., Livermore, California

ELMER

PAUL

for

Pulmonary

C. SAMSON, Oakland,

F.A.C.S.t

M.D., F.A.C.S., California

F.C.C.P.tt

Introduction The

purpose

secutive

cases

of

Administration 1951. There

arose

were

supplanted

of

being our

We

found 1947,

Although the total

in

number An Ing

of

an

more

light

tion

to

respective

what

the

we

end

there done, is

may

reason the

results

such

period

1946 procedures

increase

consideraof

that

in

completed procedure;

resections,

crossroads

in

to

analysis

future for

con-

Veterans

number

year

has been a material

95

the

a careful for

in

the

with

1950.

only a slight decrease in

increase the total

observed.

expect

deaths, total the organisms,

In as

the

in

future.

the

These

number

deaths, complications, and thoracoplasty

already appearan attempt

of

phases patients

sensitivity procedures in

to are

well, and rela-

resections.

referred

to

as being

plus stable In contrast

x-ray shadows, to those who

or changing

x-ray

deaths occurred

at

thoracoplasties

sick, operative studies of

Patients

this

of

at

during the thoracoplasty

that

a peak

steady

results done

to correlate our statistics with those We have considered several phases

on of

a

1951

I)

was

meeting

from 1949 through number of resections

evaluation

patients resistance

(Chart

been

end

information

which

resections

attempt Is made in the literature.

bring

had

for

valuable

1948

there

completed

and

us

the

tuberculosis

California, possibility

decrease

from

and

evaluate for

resections

give

a steady

thoracoplastles

to

Livermore, minds the by

done

since

was resection

might

thoracoplasties while

paper

Hospital, in our

resections

tion.

this

of pulmonary

shadows,

are those that within 30 days

well

are

who are are referred who

may

who

have

working to as

those

or sick

are who

or

not

can be directly of the date of

may

be

had capable have

hospitalized.

attributed surgery.

to

surgery

negative

sputa

of working; positive sputa Operative and

have

Material Ninety-five patients

consecutive are

living

pulmonary of

which

68

resections or

87

per

are cent

reported. have

been

Seventy-eight contacted

by

Presented at the Annual Meeting of the California Chapter of the American College of Chest Physicians, Beverly Hills, California, April 26, 1952. From the Surgical Service of the Veterans Administration Hospital, Livermore, California, with the approval of the Chief Medical Director. The statements and conclusions published by the authors are a result of their own study and do not necessarily reflect the opinion or policy of the Veterans Administration. tChlef of Surgical Services. t tArea Consultant in Thoracic Surgery, Veterans Administration. 310

-

Vol.

PULMONARY

XXIV

follow-up examination pneumonectomy while sections. The

ages

of

The

remainder

cases

were

those

RESECTIONS

FOR

or questionnaire. 62 had lobectomies

Of

who

had

varied

TUBERCULOSIS the and

pneumonectomies

from

24

to

57

entire four varied

years

of

age.

311

series, were

28 had segmental

from

25 to

The

total re-

64 years.

majority

of

the

white. Results

In

the

pulmonale

pneumonectomies, accounted

accounted There were

28 for were

still

In

sick.

Of

the

sick,

disease, for a

and period

with

62 lobectomies

(Chart

bilobectomies,

and

Four

cases

were

were true segmental There was one cor

pulmonale

were

them;

four

and

had

surgical

pneumonitls

II). living one of

the six

of

one

contact

lobe,

acute

two

one each (Chart 15 (54 per cent)

of endobronchial time of surgery lost

there

for

well

while

a reactivation; remained one and

deaths. and

three one

with one-half

Acute

irreversible

positive years

(11

had

cor shock

per

cent)

a reactivation

sputum after

from which

the we

him.

classified resections operative and

III), three

as

were

segmental and death

46 plus

resections

one due

death one

there lobectomles

upper

lobe,

segmental when

seven

lower

resections. in

reality

three

was a large caliber wedge resection. to right heart failure secondary from

CHART

transfusion

I

reaction

and

blood

to

312

SHABART

diathesis erosion

of

months

of unknown cause. the pulmonary

after

other

deaths

surgery were

three

had

reactivations

Three

cases

three are following

on

fistulas constantly had

prior

one

fourth

segmental well;

empyema

of while

well;

lobe.

This

to

segmental

death; months

nine

side.

One

one had following and

one

had

right

wedge

resection

on

upper the

while Of

sick

of

resection.

middle

the

which

two

without

resections failure

and

two from

a spread,

empyema surgery.

one of the segmental and empyema with

patient

still

had

to nine

resulted duration.

were

1953

secondary occurring

death

many

unoperated

resection and fistula

hemorrhage empyema

non-operative

and the

Sept.,

non-operative

with empyema; positive sputa

living and bronchopleural

operated

months

living

SAMSON

intrapleural from delayed for

The with

47 were

bronchopleural and two had

the

accounted

fistula

62 lobectomies,

Massive artery

cardiac.

a bronchopleural

AND

had

fistula, Of

these,

is now of expansion

dead of

lobectomy

six

left.

Complications In

the

28

operated chopleural (Chart empyema A

pneumonectomies,

there

were

side; one empyema without fistula with empyema made IV).

total

Both with subsequently of

eight

reactivations died as did

complications CHART

on

fistula four direct

in

the

63

the

un-

and one broncomplications

are still living but sick. the one with bronchopleural occurred

II:

reactivations

The

lobectomies.

one fistula.

with

Six

of

PNEUMONECTOMIES Operative Deaths

Non-operative Deaths

Total

Total

Well

Sick

28

15 54

3

4

6

11

14

22

36

Number Percent

III:

CHART

Type

two

demonstrable a total of

LOBECTOMIES

Total

Lobectomles Segmentals

AND

Well

62 4 IV:

10

SEGMENTALS Total

Sick

Operative Deaths

Non-operative Deaths

Deaths

9 0

2 0

4 1

6 1

47 3

CHART

Deaths

COMPLICATIONS

Broncho Pleural Fistula

Empyema Without

No.

Empyema

Flstula

Spreads

Pneumonectomies

28

l-D

1-D

0

2-L-S

14

Lobectomies

63

2-L-S 1-D

1-L-S

1-L-S

3-L-S

13

4

l-D

0

0

0

25

Type

Segmentals

95

Total

Complications

Reactivations

-

13

Per

cent

13.6

Vol.

PULMONARY

XXIV

which two

followed had

upper

after

was

with

which

with

segmental

death

lower crush

lobectomies in four of

effect

on

the

one

sick. The one fistula with

four

segmental No

had

reactivation,

had

an

empyema

death in this series empyema occurring

resections.

the

In

95 reported

SENSITIVITY

followed to

there

RESISTANT

seven

phrenic have any

were

13

(13.6

STUDIES

Resistant and

to

10 Mcg. Sick

the

A concomitant not appear

summary,

developed

cases.

AND Sensitive

He

complications

complications.

in

V:

but

313

cases and

one middle lobectomy. lower lobectomies did

of

complications

three

empyema,

empyema.

the seven

incidence

CHART

the

with or

TUBERCULOSIS

resection.

in

fistula

cent)

in

fistulas

one

bronchopleural

the

FOR

All of these are living followed a bronchopleural

lobectomy

There

per

lobectomies

bronchopleural

without fistula. of complications

RESECTIONS

or

to

10 Mcg.

Sensitive

Resistant

to 100 Mcg. Sick or

to

100 Meg. Sick

or

No.

Well

Dead

Well

Dead

Well

Dead

Pneumonectomies

14

2

4

4

0

1

3

Lobectomies

50

34

8

5

0

2

1

3

2

1

0

0

0

0

3/43

457

Segmentals Total

Per

and

cent

38/75

CHART

VI:

13/25

PNEUMONECTOMIES Sick

.

No.

Thoracoplasty

(Percent)

WeT!

16

Before

6

After

(Percent)

CHART

VII: No.

Thoracoplasty (Per cent)

Before

No Thoracoplasty (Percent) Thoracoplasty Concomitant Thoracoplasty (Per cent)

After

or

Complications

10

6

No Thoracoplasty (Percent) Thoracoplasty

9/100

1

Operative

Total

Deaths

Deaths

4

63

6

25

1 17

33

2

0

4

2

0

67

33

UPPER

6

38

4

67

0

LOBECTOMIES Well

Sick or Complications

Operative Deaths

Total Deaths

12

7 58

3 25

1 8

2 17

5

3 60

2 40

0

0

0

0

0

0

0

29

26 90

2 7

0

2 7

314

SHABART

AND

Sensitivity Those

cases

tion were resistant

to

prognosis.

which

then 100

In

Both that

of

and of

to

three

In the three 10 mIcrograms

to

had

resistant

to

but

10 micrograms

Before

No Thoracoplasty (Percent) Thoracoplasty (Per cent)

After

Concomitant Thoracoplasty (Percent)

of all

ALL

Sweet,

(Per

were V).

of

to those

sensitive

to

of

this

kind

of

which

which were

one found

was to

dead. be

sensitive

or

Complications

Operative Deaths

Total Deaths

3

1 33

1 33

1 33

2 66

1

1 100

0

0

0

2

2 100

0

0

0

2

1 50

1 50

0

0

IX

No.

Well

745

496

or

Complications

Operative Deaths

Total Deaths

47

137

Day

cent)

Bailey, Brantlgan

95

66.5

Glover (Per cent)

347

DavIdson (Per cent)

200

Overholt (Per cent)

426

Shabart, (Percent)

Six

were still sick and one and all were well. There

Sick

Chamberlain, Hlmmelstein,

cases guarded

OTHERS

Well

CHART

Gale,

were

resec-

resistant (Chart and

two

Sick

Thoracoplasty (Per cent)

to

considered highly studies.

studies

studied, is dead.

No.

1953

micrograms.

micrograms

VIII:

a

such

Seven of these 100 micrograms

segmental resections and of these one

CHART

100

prior

to 100 micrograms

deaths,

preoperative

100

had

to

operative

resistant

we have having

sensitive to 100

sensitive

than

studies

as

14 cases four were resistant

to 10 micrograms. were sensitive to

cases

resistance

of this writing, streptomycin

were other

50 lobectomies

42 were sensitive dead. Five cases three

and

and were

reactivation died,

10 micrograms

were

of

Sept.,

Resistance

20 pneumonectomies,

subsequently A total

As

10 micrograms; while four

cases

and

sensitivity

evaluated. micrograms

the

sensitive to 10 micrograms;

had

SAMSON

Samson

95

12.6

242 70 151 75.5

-

18.3

7.7

22

4.5

20

302 70.9 65 68

6.3

13 14

38 8.9

87 20.4

6 6

17 18

Vol.

PULMONARY

XXIV

Combining to 10 micrograms were

sick

resections, of which

or dead.

were all resistant or

all

RESECTIONS

Nine

a total of 51 (75 per cent),

38 cases

living and well. to 100 micrograms

FOR

resistant

Three

to

TUBERCULOSIS

cases were

were well;

10 but

(43 per cent), were well while

found and

sensitive of four

315

to be sensitive 13 (25 per cent), to

the (57

100

total per

micrograms

of seven cent), were

cases sick

dead. Although

100

we

resected

micrograms,

nificant

in

feel

it

points

that

results

can

be

was been

the greatest confirmed

relatively

we

our

expected.

to In

the

bear out we must

this opinion. expect an

development When increase

these was

sensitivity found that

-

sensitive

it to

only group

a

aid in eliminating by others. He

An

evaluation

of

whether

resection In which

or the

whether

six dead. complications after We

cases

in

was was

none

28 pneumonectomies, 10 were living and

subsequently

has

the

died. Six

There

had while

resection, occurred

in

were

most

at

the

are

this

group.

anxious

and

Resection on

was

done

surgical

and

two

to

evaluate

CHART

developed procedure

X

of

micrograms

occurred

their

in

end

the

results

concomitantly

previous bronchopleural

deaths

this

100

comwere

with

VI).

and

one of which died. Of those

well

help resection,

postoperative complications

or

(Chart

poor

statistics

to

basis

after,

16 patients had One developed four

Our

ones

the

before,

whom streptomycin

selected for mortality.

sensitive

remaining

made

no thoracoplasty, four subsequently

four

group

the

is sig-

which has since should be made to

with the group of these cases with

done

all

well. were

morbidity effort

to

dead

in that

resistance.

and

resistant or

patients

cases are and eventual

of

group sick

emphasized

streptomycin

while

thoracoplasty

operative

postoperative that every

Thoracoplasty and

the cent

such resistant in morbidity

resulted, micrograms.

100

of

in

57 per

J. C. Jones

studies nine

10 micrograms;

one complication resistant to

of

loss

stated

of

cases

result

1950,

prevent

Grouping plications,

fewer

end

thoracoplasty fistula a total

is well having

number and two thoracoplasty

complications. in

of and

lobectomies,

No

of had death par-

316

SHABART

ticularly

upper

comitant

thoracoplasty

Twelve and

lobectomles,

cases

three

tions. In

the

were

eight

(Chart which

is

which is well

were

well

are

well.

Two

and

one

done on five with those

cases

and

three

and

who

opinion

that

which

death

seven

and

are

a total

Twenty-nine well. Two

well

of

cases. Three patients still sick. There were

resection. living and

con-

VII). of

operative

done after and 26 are

one

two

are well no cases cases had complica-

had

lobectomies

with

segmental

done

before

complications.

There

was

of two. There of thoracoplasty concomitant

developed

plus

thoracoplasties

had

made a total and two cases

well

the

(Chart

resection

one

resections

there

one

had

1953

deaths.

bilobar

VIII),

death who

was occurred

two

have

Sept.,

employed

before with

was

SAMSON

we be

thoracoplasty

thoracoplasty thoracoplasty

There

best

complications

deaths. No thoracoplasty and two complications In which concomitant

where can

had

had

AND

was one with after resection thoracoplasty

one

no

were

resection resection

of

operative

thoracoplasty both of whom done

with

one

a complication. Discussion

Such

workers

melstein and cent

in this

and 1951 well

in which and 12.6

6.3 per cent cases with

Sweet,

IX)

reported

Day,

reported

a total dead cent deaths

and

a total

series

of

Chamberlain, their

number 426

in

cases operative

In 1950 of whom

Him-

1949,

1950

revealed 66.5 mortality

Glover reported 242 or 70 per

17 deaths

likewise

(18

per

compares

cent). to

per was 347 cent

for tubercle bacilli. The end general pattern with 65 (68 per still sick. There were 6 (6 per of

cases

Bailey,

resections

on 745 over-all

of 18.3 per cent. with 269 living

and 7.7 per cent positive of cases fits well into this well and 13 (14 per cent)

deaths

recent

as Gale,

(Chart

their combined efforts per cent still sick. The

with 22 per

were negative of our series reported as operative

field

Brantigan

result cent) cent)

Overholt’s

these

reported

series. Of

a total

group

and

anticipated basis of or

of it

our

There following resections

be

to even

presumed

or

from

living the

four that

over the as those any

surgery.

pneumonectomy, on a long

cases that

deaths,

operation as well

resection

monectomy getting

must

survival

subsequent hazardous It appears

operative

in this statistics

segmental

mediate

six

more

well

against

patient

the

guarded

has

10 of

the

it appears basis. With

term

and

a

in

pneumonectomy outcome

must

other resection procedures. of others, It appears that

combination With

lobectomy

occurred

has

a

better

,total

dead

that this 54 per cent

76 per

cent

again

the

for

chance of

all

of

im-

17 occurrIng

procedure of the

is post

other

advantage

be

On the lobectomy

more pneu-

resections, of ultimately

well. were four (14 pneumonectomy combined.

ported by Clagett pneumonectomies

per

Our and and

cent) while complication

Seybold 28 per

in cent

postoperative nine (14 per rate 1948 whose in lobectomies;

complications cent) followed

again rates

compares were or the

occurring all other to

20 per report

that

re-

cent for of Jones

-9

PULMONARY

Vol.

XXIV

in

1950

on

Davidson

88 in

excluding reactivatlons with and only

cases

1950

RESECTIONS

with with

Our

study

of

sensitivity

sensitive to 100

to 10 micrograms micrograms. Four

micrograms. longer

the other

21 per

TUBERCULOSIS

complications; cent.

in the development

We

can

the

that

these suitable factors might certainly fall guarded.

none were on

who

factor to ideally present

is

his

to

be

stated

which

at

being

this

the

seen

use

the

basis

time.

We

alter

the

is

often

Conversely, bronchoscopy

Does the

Can

ing

involvement

within

the

diseased

wall area

it be

feel

that

antimicrobial fails

to

Rather that

some

possibly

than

a more

find

figures

we

having

that if no a poor end

these

at

resistant

surgery

factors The

outstanding

on

mucosa dividing

the submucosa mucosa. This the

resected

bronchus.

quite report

agents

although

materially

effect

the

normal bronchial

lymphatic

suture

the

past two thoracoplasty

pneumonectomy cases In

and

in

group. we

offer

no

we have resection.

This reason

been

concomitant

but

reasons stated below, we tics showed that of those

now who

would had

of

those

that

had

impressed this series

why

group

and

been In

has

pneumonectomy

well

the

years

on

an the

advocate previous

thoracoplasty

actual

with none survey

thoracoplasty basis

of

our

at

effec-

involvement

across

of the

the

and more gross obser-

bronchus appear the pathologist

resection

present

bronchial

surgery,

of

cannot

being

such

a grossly

Involved

bronchus

should be done even with plastic closure of same If necessary. There to be no question that inadvertently entering a cavity and causing contamination of the pleural space increases morbidity and mortality which the antimicrobial agents may have only limited value. For comitant

to

that as

in

cases.

In

to attempt

radical

were

who was sensitive were resistant

What all the other which are resistant should be highly

appearing

study

and have

but two carries

who

this mean chance of

surgical

microscopic

of our fistula

produced

these

drugs

suggest

to

dead grave,

dead

following

of disease exists normal appearing by

proper? we

only

of

sensitive to 10 mIcrograms? with the fact that without

newer

these

All

10 micrograms

course

negative

times the mucosa surgery only to

tuberculosis. mucosal

of

bronchoscope

confirmed

many and

the

to

rather

that gross evidence tissue with rather

vation

like

course of

the

of

eventual

would

of

can and will occur. to say. Those cases which the prognosis

some

their

appearance

through

bronchus, peripheral

of

alter

materially

one as

the

are

or

sick or dead or dead who to

those

complications,

streptomycin sick

was sick

advantage. that he stands

factors complications be we are not prepared into the category in

materially

as all although

were

sensitive

finally

nine

lobectomles. bronchopleural

of

patients

suspect

a case

Whether will

our

upper

result in spite of the fact that his organisms are We do not believe this to be so, but are impressed

cases

of

organisms

13

while of seven

would

accept

best prognostic factors are

of in

317

and

Six

appears to be a serious complication still sick. Empyema without fistula, better prognosis. information

no

cent

of

occurred but the

alive;

interesting

100

per

a total

pneumonectomies, are still

empyema they are a slightly

6.8

FOR

the was of

use done 95

of in

conthe

consecutive

was statistics

seems gross upon

not and

done for

such a procedure. Our statisthoracoplasty 63 per cent were after

resection

67 per

cent

were

318

SHABART

well; while those We feel that this ciated

with

there because

of

enon as

was

chance

we

report has

We

prefer In

the

may cases

separate

done

had no thoracoplasty 14 lobectomles with controlled; whIch 95

per

while cent

combined operative

quite the that the

Recent

the

reports with for

on

judgment in to improve number

of

pulmonary

resection

resected

and four while In

the the

60

dead. had

was late

resection

upper resec-

cent

well

who

per

cent

well

who

in 1952 reported all are apparently 38

cases with

In our series, no thoracoplasty.

7 per variety.

is

with

per

cent and We feel

a skeptical It has been

Improvement and 1950 can 10

were

in 1947. This 1950 a greater

tlons in which pneumonectomies, against

22 four

of For

done

a so-called

for

attitude our

relatively

cases this

against

has reason

in 18 comIn

we had this is

towards experience

non-shocking

played we

the

total

Chart.”

to some be explained

extent (Chart by the fact

certainly campaign

26 cases in 1951,

pneumonectomies.

for was

more made

In

were of the 24 varieties There

shown We

number

of

think

our

X). that

seven experience the field

better

have along

an important attempted to

We

with

made

have

mortality. techniques

“Learning

pneumonectomies

of the while

tuberculosis

morbidity and Improved individual

selection results.

resections on

out our Individual In the years 1949

done

after

the

cent

thoracoplasty 58

1951 reported 20 lobectomies

one who

have signified death rate.

immediately

(1)

and Carr in which

rate the

38 per

segmental

and

and those

our total death deaths were of

a lower postoperative a long time that

complications

cases

positive cent of

to find pneuthoracoplasty

with to

resection;

alpneuwhich

procedure

categories:

contrast

Ellis, Clagett thoracoplasty

one 40 per

with

death rate of was done first.

concomitant

Riley

reasons,

patient.

results pected wiser helping

in

to

as some workers because of a high

thoracoplasty

to

had

phenomand

our experience to perform under

two

by

cripple

This

these

thoracoplasty another

Toby and Grismer in well. Woodington reported

procedure death. The

significant procedure

For

lobectomies

well

procedure. concomitant

bacteriologically negative, plications developed In the no

cent

previous

Conklin, were

groups.

into and

who

90 per

Cournand

our total resection

lobectomies

lobectomies

were

thoracoplasty

in the

bilobectomies

upper

there

lung.

age

well. asso-

other lung over distention,

remaining Lester,

1953

pneumonectomy the

and

has been technically

be reflected in which the

(2)

It

with

a respiratory

a concomitant of eliminating

indicated. more difficult

and

resection had

feel

used

were place

becoming

the

Berry;

older

17 per cent a definite

lesions in by preventing

on

in

and

none, we the advantage

this those to

lobectomies, tion.

changes the

becomes much

we suspect none In

later

by Cournand in

thus active time

same

patient

particularly

eventually monectomy and over

the

emphysematous reported

occurring

though monectomy

of

questionable At the

Sept.,

only having

Thoracoplasty

keep stabilized over distention.

is less

SAMSON

that had no thoracoplasty speaks for thoracoplasty

pneumonectomy.

tends to preventing

AND

suswith

role correlate

deaths

in and

chart

bears

The discrepancy in 1949 of the

being

done

in

24 1948

In this procedure; of subtotal resec-

subtotal of subtotal

type

against resections

occurred

only

one

four were surgical

Vol.

PULMONARY

XXIV

death

in

become

RESECTIONS

pneumonectomies more

in

efficient

in

FOR

these

the

two

TUBERCULOSIS

years.

subtotal

Here

variety

319

again

of

we

feel

we

have

resection.

SUMMARY 1)

number

The

well

of

compare

2) by

favorably post

3)

Patients upon

series

of

95 who

reported

resection

sensitive

to

having

the

as

100 micrograms

postoperative 4) Upper cidence 5)

this

those do

in

not

subsequently

the

exceed

became

literature.

those

previously

reported

workers.

looked

can

of

well

10

of

prognostic

be expected

to have

with

patients

a higher

incidence is

resection

should but

for

of

not

those

percentage

thoracoplasty

a lower experience

of pulmonary

streptomycin standard,

concomitant

and

resection

results

micrograms

better

morbidity. lobectomies

Individual

end

in

with

Complications other

to

patients

be

resistant of Increased

gave

a higher

in-

complications.

another

factor

in

improving

the

tuberculosis.

RESTJMEN

1)

El nUmero

resultaron en

la 2)

han

de

enfermos

se

puede

blen,

literatura. Las complicaciones sido

por

enfermos no

La

serie

de

de

individual de

series

de

y cinco

con

la resecciOn

no

los

exceden

mas

tarde

casos

relatados

a las

que

antes

autores.

superiores recuperados

finales

noventa

favorablemente

sensibilidad verse como

blen

experiencia

resultados

esta

de germenes a la estreptomicina a los que tienen el mejor prognOstico,

a 100 mlcrogramos puede de morbilidad postoperatoria.,

Las lobectomlas de enfermos

5)

otros

con deben

pero los resistentes mayor porcentaje

los

en

despues

referidas

3) Los microgramos

4) mayor

que comparar

en

esperarse

que

con

toracoplastla dieron y menor frecuencia de

las

resecciones

la resecciOn

es otro

pulmonar

por

10

presenten

el

una frecuencia complicadlones.

factor

para

mejorar

tuberculosis.

RESUME

1) sont

Dans en

ces proportion

95

cas,

ceux

relativement

qui

furent

favorable

si

publi#{233}s jusqu’a present. 2) Les complications apr#{232}s l’ex#{233}r#{232}se n’ont pas rapportees ant#{233}rleurement par d’autres auteurs. 3) vent ii

est

Les

malades

pas

etre

qui

sont

sensibles

consid#{233}r#{233}s comme

incontestable

que

consld#{233}r#{233}s comme

ayant

qui plus

l’on

de

ce

r#{233}sistent

grand

stabilis#{233}s

compare

avec

les

cas

d#{233}pass#{233} celles qui ont

10 gammas

ayant

ceux un

a

ult#{233}rleurement

de

fait

un

a

ioo

pourcentage

streptomyclne meilleur gammas de

ne pronostic peuvent

complications

ete

peumais #{234}tre post-

op#{233}ratoires. 4) une

Les plus

lobectomies sup#{233}rleures avec grande proportion de stabilisations

complications. 5) L’experience tats

dans

les

de

l’op#{233}rateur

r#{233}sections

pulmonaires

est

un pour

thoracoplastie et un

assodl#{233}e ont donn#{233} nombre moms eleve de

facteur

favorise

qui

tuberculose.

les

bons

resul-