Late Complication of Lucite Ball Plombage; Surgical Cure

776

MORTEZA SALSALI

sera of relatives to the levels of heterozygotes also support the correctness of the diagnosis in the patient studied. The onset of the patient's pulmonary disease was at two years of age. The left lung was affected by the disease. The diagnosis of pulmonary emphysema was established through chest films, clinical picture, but especially by the lung biopsy and by the determination of static lung compliance. The obstruction of the airways was proved by the abnormally low values of some functional characteristics of airways (Table 1). The results of lung function studies are the same as those reported by others. 2 , 6 , 8 From the radiospirometric and pulmonary blood flow studies ventilation and perfusion of the left lung are shown to be markedly reduced. A part of this abnormality was caused by the removal of the lower lobe. Repeated lung function studies also showed that lung volume was stationary and there was static lung compliance. The indices of the airway obstruction are worsening slightly. It is also interesting to note in this patient that after the inhalation of a bronchodilator his airway conductance improved significantly but his FEV 1 and maximum expiratory flow rates very little. This might indicate a certain bronchospastic component of the disease as well as the site of the action of the bronchodilator. In spite of severe lung function disturbance, the patient had only a partial respiratory insufficiency with hypoxemia and with normal acid-base balance. REFERENCES

1 Laurell CB, Eriksson S: The electrophoretic alpha-Lglobulin pattern of serum in alpha-I-antitrypsin deficiency. Scand J Clio Lab Invest 15:132-140, 1963 2 Black LF, Hyatt RE, Stubbs SE: Mechanism of expiratory airflow limitation in chronic obstructive pulmonary disease associated with alpha1antitrypsin deficiency. Am Rev Resp Dis 105:891-899, 1972 3 Eriksson S: Studies in alphalantitrypsin deficiency. Acta Med Scand Suppl432:177, 1965 4 Liebennan J, Mittman C, Schneider AS: Screening for homozygous and beterozygous alphaJ-antitrypsin deficiency: Protein electrophoresis on cellulose acetate membrane. JAMA 210:2055-2060, 1969 5 Mittman C: Summary of symposium on pulmonary emphysema and proteolysis. Am Rev Resp Dis 105:430-448, 1972 6 Townly RG, Ryning F, Lynch H, et al: Obstructive lung disease in hereditary alphal-antitrypsin deficiency. JAMA 214:3~331, 1970 7 Feigelson J, Pecau Y, Mazodier P, et al: Manifestations respiratoires a repetition chez un enfant de trois ans. Role possible d'un deficit en alpha-l-antitrypsine. Arch Franc Pediat 27 :991, 1970 8 Talamo RC, Levison H, Lynch MJ, et al: Symptomatic pulmonary emphysema in childhood associated with hereditary alpha-I-antitrypsin and elastase inhibitor deficiency. J Pediat 79:20-26, 1971 9 Evans HE, Levi M, Mandl I: Serum enzyme concentration in respiratory distress syndrome. Am Rev Resp Dis 101:359-363,1970 10 Kotas RV, Fazen LE, Moore TE: Umbilical cord serum

trypsin inhibitor capacity and the idiopathic respiratory distress syndrome. J Pediat 81 :593-599, 1972 11 Nohl M, Menner K, de Sousa F, et al: Alpha-I-Antitrypsin Konzentration in Serum Neugeborener mit und ohne Atemstorungen. Z Kinderheilk 113:145-150, 1972 12 Zapletal A, Motoyama EK, van de Woestijne KP, et al: Maximum expiratory flow-volume curves and airway conductance in children and adolescents. J Appl Physiol 26:308-316, 1969 13 Zapletal A, Samlmek M, Paul T: Indices of the elastic properties of the lungs in healthy children and adolescents. Cs Pediat 27:276-281,1972 (in Czech)

late Complication of Lucite Ball Plombage; Surgical Cure* Morteza Salsali, M.D.--

w.

A 56-year-old white w~ developed, 10 years after a Iocite baD ........, tubercalo_ extrapIeuni empyema eDencling to tile .-IN:1It_elMlS recioB. She treated successfully wIdt combiBed ...tituberc.1osIs drugs and surgical resectiH wldch elmillated pel'lllalleatly the old tboracopl8sty, napyema ... puhaoaary lesion. plombage using lucite balls, recommended E"trapleural by Wilson! in 1948, proved to be associated with

serious complications varying from local pain to lung perforation and extrapleural empyema. Thus, the procedure has not been done frequently and now, very late complications of lucite ball plombage are seen but with extreme rarity. 2 A patient was seen who developed empyema 20 years after this procedure. Because of a new approach used in her management, her case history is presented. CASE REPoRT

A 55-year-old white woman was seen with empyema who had undergone lucite ball plombage 20 years previously. She was working until November of 1968 when she was admitted to the hospital with a swelling on the right chest wall. She had had bilateral pulmonary tuberculosis in her teens and was treated for a period of ten years with pneumothorax, pneumoperitoneum and right phrenicolysis. In April of 1949, she had undergone lucite ball extrapleural plombage at Long Beach General Hospital in California, by Dr. Eugene Campanez. She had not been treated at any time with antituberculosis drugs. In September of 1968 she developed a chill and was found to have a low-grade fever. She then noticed the appearance of a mass over the chest wall. She had lost ten pounds. Her -From Thoracic Section, Pack Medical Group, New York

c:uy.

\

Supported by the Pack Medical Foundation. - -Thoracic Surgeon, Pack Medical Group. Reprint requests: Dr. Salsoli, 139 East 36th Street, New York City 10061

CHEST, VOL. 64, NO.6, DECEMBER, 1973

LATE COMPLICATION OF LUCITE BALL PLOMBAGE temperature was l00.2°F; blood pressure 130/80 and pulse 90. Other positive findings were an old surgical scar on the right chest. There was a 10 em in diameter, nontender fluctuating abscess lateral to the tail of the right breast. Its overlying skin was slightly reddened but was not warm. Breath sounds were diminished over the right upper hemithorax. A chest x-ray picture showed the presence of numerous spherical densities in the right upper thoracic field (Fig 1). Needle aspiration of the abscess showed no bacteria on Gram stains. Skin tests showed only positive purified protein derivative (PPD). The extrapleural empyema which had extended to the subcutaneous region was drained by rib resection in November, 1968. All 27 plastic spheres were removed. The empyematous cavity was drained. No air leak was noted. The cavity then was irrigated daily with Dakin solution. Prior to surgery, the patient was put on streptomycin and isoniazid but then switched to INH and PAS. Only culture of the empyematous pus grew acid-fast bacilli and that after three weeks. A chest tomogram and bronchogram demonstrated no pulmonary disease on either side except for a collapsed right , upper lobe. A biopsy specimen was obtained from the wall of the empyema over the collapsed lung which showed no malignant degeneration. During the six weeks following the drainage of empyema, the patient's general condition improved. She became afebrile and gained two pounds. On January 14, 1969 she was operated upon. It was noted that both the middle lobe and superior segment of the right lower lobe were free of disease and interlobar fissures were well developed. Apical and posterior segments of the right upper lobe were completely collapsed but anterior segment was still expanding. Thus, a right upper lobectomy was done. Because of the previous plombage procedure the pulmonary vein to the right upper lobe was dissected free and divided first, then interlobar fissures were completed and the right

777

FIGURE 2. A chest x-ray picture taken 12 months after surgery shows complete filling of right hemithorax with expanded right middle and lower lobes. upper lobe bronchus was dissected and divided. Lastly, the pulmonary artery to the right upper lobe which now was exposed to the operative field was divided between ligatures. Then the plombage shelf was dissected off the chest wall everywhere around the attachment to the thoracic wall. There was minimal reaction produced in the mediastinum, thus the superior vena cava and right innominate vein could be easily visualized during the course of dissection, but attachment of the shelf to the chest wall was ossified, and the bone-cutter had to be used for this part of the dissection. The right upper lobe in continuity with plombage shelf was removed. The right lower and middle lobes were expanded and they then filled up the entire right hemithorax. Postoperatively the patient did well. There was no air leak and the right hemithorax remained filled with the expanded right middle and lower lobes. She was kept on INH and PAS for six months after surgery. The patient is well without any disease for more than four years. She is back to her job with the same level of proficiency as before surgery and can participate in many activities that she denied herself prior to surgery. DISCUSSION

FIGURE 1. A chest x-ray film taken on the patient's admission to the hospital shows lucite balls in upper right hemithorax and haziness in the lower part of plombage which suggests fluid accumulation.

CHEST, VOL. 64, NO.6, DECEMBER, 1973

Because of the early low mortality and simplicity, lucite ball plombage was accepted quickly, particularly outside the United States. However, accumulated followup data on these earlier works showed a high incidence of late complications varying from chest pain, lung perforation, bronchoextrapleural fistula, extra pleural tuberculous and nontuberculous empyema and superior vena caval obstruction. 3,. In the second phase of the evolution of this procedure, two factors entered the picture. One was the advent and administration of antibiotics and antituberculosis chemo-

CAlICK, BISHOP

778 therapy and the second was the use of extraperiosteal pneumolysis instead of extrapleural pneumolysis." Although during this period the incidence of early postoperative complications of the type mentioned definitely decreased, that of delayed complications and mortality remained high and even equalled the early mortality of the classic thoracoplasty." To obviate this early and late complication, the procedure was done in two stages and Michelson 7 proposed that the lucite ball plombage and the overlying ribs be removed in the second stage six weeks after the first stage. He reported no late complications in 25 patients so treated. The accepted treatment for tuberculous extrapleural empyema has been completion of thoracoplasty." However, when this complication is seen very late, as was the situation in our case, the Shade thoracoplasty and partial scapulectomy with transplantation of muscle are necessary to obviate the space. But when the pulmonary disease is not bilateral and is confined to only one side and to one lobe, and the remaining lobes are not involved by the disease process, it then seems advisable to eliminate permanently the infected source and not to resort to classic thoracoplasty which leaves the patient with foci of tuberculosis in situ. REFERENCES

1 Wilson DA: Extrapleural pneumolysis with lucite plombage. J Thorac Surg 17:111-122,1948 2 Seibert EC, Tabrisky J: Lucite extraperiosteal plombage. Roentgenologic review of late complication. Am J Roentgen 100:593-596, 1967 3 Inada K, Sato A, Kishimoto S, et al: Evaluation of extrapleural pneumolysis with filling with plastic balls: Analytic studies on 63 patients from whom plastic balls were removed. J Thorac Surg 27 :503-513, 1954 4 Trent JC, Moody JD, Hiatt JS: An evaluation of extrapleural pneumolysis with lucite plombage. J Thorac Surg 18: 173-1BO, 1949

5 Woods FM, Walker JH, Schmidt I: Extraperiosteal temporary plombage in thoracoplasty: A preliminary report. Dis Chest 18:401-412, 1950 6 Cleland WP: Discussion on paper by Wilson IN et al. J Thorac Surg 32:813-815, 1956 7 Michelson E: Discussion on paper by Wilson IN et al. J Thorac Surg 32:816, 1956

Pericardial Effusion Arthritis*

In

Table I-Hemodynamic Data Chamber

Pressure, mm Hg (Mean)

Right atrium Pulmonary artery Pulmonary wedge Atrial Ventricular Right ventricle

23/12 13 10 23/10

(Il) (18) (12)

bination may be of value in diagnosis. Similarities between the properties of rbeumatoid pleural and pericardial Ouids are noted. he composition of the pericardial fluid in the rheuT matoid effusions has not been emphasized.' In the

case under study, it is felt that it would be of interest to obtain these values, since low glucose concentrations have been routinely found in the pleural effusions of such patients. CASE REPORT

The patient is a 44-year-old woman who has severe rheumatoid arthritis of 18 years' duration. Features of her disease include: (1) morning stiffness for two hours; (2) pain on motion and deformities of multiple joints; (3) swelling of the metacarpal, phalangeal, elbow, and knee joints bilaterally; ( 4) subcutaneous nodules on the extensor surfaces of the elbows; and (5) a positive rheumatoid factor test. Current medications include phenylbutazone and aspirin. Previous therapy included steroids from 1952 to 1964. She developed an ulcer at that time, and steroid therapy was then stopped. She had not received gold or antimalarial treatment. She entered the hospital because of palpitations, which were found to be due to paroxysmal atrial tachycardia. The patient was noted to have distended neck veins and tender hepatomegaly. Her joint disease was not noted to be acutely exacerbated at the time, nor was any change noted in the number or dimensions of her rheumatoid nodules. She converted to sinus rhythm with 0.5 mg of digoxin given intravenously. A pericardial friction rub was detected and a symmetrically enlarged heart was seen on chest roentgenogram. Results of skin tests including tuberculin and fungal antigens were negative. Results of a test for lupus erythema-

Rheumatoid

Arthur Calick, M.D., and Robert Bishop, M.D.

A case of rheumatoid pericardial effusion with restriction to ventricular diastolic fiDing is discussed. Diminished glucose concentrations and increased lactic dehydrogenase (LOU) were found in the pericardial Ouid. This com"From the Naval Hospital at St. Albans, New York.

30 20 ts

to S

FIGURE 1. Right atrial pressure curve indicating "MOO shaped pattern of restrictive heart disease.

CHEST, VOL. 64, NO.6, DECEMBER, 1973