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Results of Pulmonary Resection in the Treatment of Tuberculosis
Results of Pulmonary Resection in the Treatment of Tuberculosis" MORGAN
K. C. Lu,
M.D., F.C.C.P.
Hong Kong
T
H IS STUDY REPRESENTS A REVIEW OF
360 tuberculous patients subjected to 364 pulmonary resections between May, 1955 and September, 1960. All the patients with the exception of 26, who were discovered to have isolated nodular opacity in the lung by chest survey and presented negative sputum status, had been treated in a well-coordinated program consisting of bed rest and antituberculosis chemotherapy. The decision to operate on these patients was, in the majority of cases, reached at chest conferences. The duration of postoperative convalescence in hospital varies from four to six months, as determined by the progress of the individual case. The period of postoperative chemotherapy consists of a minimum of 16 months, and it could be extended to two years or more as the condition of the individual patient may require. The minimal follow-up for the patients alive in January, 1960 was four months, the maximum being four years and six months. The postoperative period consists of an arbitrary period of three months following operation. The three standard antituberculosis drugs employed here are streptomycin, isoniazid and paraaminosalicylic acid. GENERAL STATISTICS
The general statistics, including sex, age, race, types of resection, preoperative chemotherapy, and preoperative sputum status, are presented in Table 1. Note the preponderance of segmental resection in the whole series. This indicates simply that a large group of patients belong to the well-selected group for resectional surgery. In most instances, the excision of the apical segment or the apico-posterior segments of the upper lobe was carried out. *From the Department of Surgery, Queen Mary Hospital, Hong Kong.
In a few occasions on the left side tri-segmental resection of the ~pper lobe with the preservation of the lingular segment was performed. In seven patients, segmental resection was used in addition to lobectomy. This group consists mainly of the combination of upper lobectomy and resection of the superior segment of the lower lobe. In 29 who had wedge excision, the nature of the lesion was usually a well-encapsulated, peripherally situated nodular opacity varying from 2 to 3 ern. in diameter. Of the entire series of 364 resections, 321 were primary and 43 were secondary resections following previous collapse therapy, or ipsilateral or contralateral resection. SPECIFIC INDICATIONS FOR RESECTION
The specific indications for resection are listed in Table 2. There are many patients who, listed under the category of diffuse or localized, dense residual infiltrations with or without cavity after chemotherapy, could have been good candidates for thoracoplasty, but resection was elected as the procedure of choice. With our gain in experience dealing with resectional surgery in the last five years, the indications for segmental resection are rapidly extending to include quite a large group with localized target focus of infiltrations remaining after treatment with bed rest and chemotherapy. Other well-selected cases SlJfh as those with large isolated nodular opacity, lobar atelectasis, chronic fibrotic cavitary lesion, tension cavity, and cavities in the superior segment of the lower lobe have met most of the essential criteria used in accepting patients for resection. In the group listed under the category of thoracoplasty failure, we believe that resection is the procedure of choice rather than revision thoracoplasty, as the underlying pathologic cause for the 193
194
Diseases of the Chest
MORGAN K. C. LU
TABLE I-GENERAL STATISTICS Pulmonary Resection for Tuberculosis-May, 1955 to September, 1959 Total Resections-364 Total Patients -360 Operations Lobectomy
Segmental Resection
135
183
Wedge Excision
~bectomy Plus Segmental Resection
Pneumonectomy
7
10
29
Previous Treatment: (A) No Previous Treatment (Primary Resection) .. .._._ .. .. .. .. .321 (B) Previous Collapse Therapy -. .. -- -- . 39 Ipsilateral Pneumothorax ..----..----.----. '--'-..--- - ---"---' .--..----. - ----..--.----.--- 20 Ipsilateral Phrenic Crush and Pneumoperitoneum.-.-_ ..__ ._.._.._ __ ._ _ --_ __ ..__ ._ 14 - ---- ..__._.. .. . -.. .._ . 3 Ipsilateral Thoracoplasty .--.--..---Ipsilateral Extrafascial Polythene Ball ..---_ __ ..__ .-.--- --.-.--..---_ .. .__ .----_.. 1 Contralateral Thoracoplasty - -------------------- ---- --.--------- --- -.----..---- 1 (C) Previous Resection ..---- ----..------ ----.----..----..----. '--.--.---- --------------..---- 4 _ e • • _ . __ • • • • • _ • • • • • •
Sex Male Female
No. 274
86
Races Chinese White Indian Portuguese
Preoperative Chemotherapy: )10 Chemotherapy Chemotherapy of three men ths to over two yean
No.
Age
351
8 to 20 years 21 to 40 yean 41 to 55 years
4 3 2 No. 26
••
••.••••
No. 21 291
Per cent 6
48
13
81
Preoperative Sputum Status: Positive (by Smear or Culture) Negative (by Smear and Culture)
No. 135 225
334
persistent positive sputum is either bronchial disease or residual cavity, which could hardly be closed by further collapse therapy. In the 13 patients with bronchiectasis, the tuberculous nature of the bronchial lesion was only known in less than half of the cases prior to pathologic examination of the resected lung specimens. Pneumonectomy was the operation of choice in ten patients, who suffered from extensive uni-
lateral disease. In one patient with chronic pleurisy and lesion in a collapsed upper lobe, decortication plus segmental resection were successfully performed. There are four patients with secondary resection. ANALYSIS OF POSTOPERATIVE COMPLICATIONS
Table 3 gives a full statistical account of the postoperative complications for the en-
TABLE 2-SPECIFIC INDICATIONS Radiologic Status 1. Diffuse or Localized, Dense Infiltration in Upper Lobe with or without Cavity after Chemotherapy (Mainly Apico-Posterior Segments) 2. Isolated Nodular Opacity 3. Lobar Atelectasis 4. Fibrotic Cavitary Lesion 5. Tension Cavity 6. Lower Lobe Disease 7. Bronchiectalis 8. Thoracoplasty Failure 9. Extensive lJ nilateral Disease 10. Chronic Pleurisy with Collapsed Upper Lobe (Decortication plus Resection) 11. Secondary Resection for Ipsilateral Reactivation 12. Secondary Resection for Contralateral Disease
No.
Per cent
216
60
58 16 31 1 10 13 4 10 1
16
3 1
4.3 8.4 0.27 2.7 3.4 1.1
2.7 0.27
0.8 0.27
Volume 41, No.2 February, 1962
195
RESECTION IN TUBERCULOSIS
tire group of patients subjected to various types of resection. In the last column of the same table the complete figures of incidence of all types of complication are put together according to the type of resection. 1. Severe Postoperative Hemorrhage
There were 13 who had a total blood loss of more than 1000 cc. during the first 24 to 48 hours after operation, and exhibited symptoms and signs of peripheral vascular failure. The main cause of hemorrhage is not easily assessed, and the bleeding was usually of slow, prolonged oozing type. In most instances, the blood had no tendency to form clots and drained freely
from the pleural cavity into the bedside drainage bottle. The question of fibrinolysis was considered, but we had not undertaken special investigations into the matter. All the 13 patients except one, who came down with partially collapsed lung and reactivation of disease in the latter course of the postoperative period, recovered fully without further complication. The incidence of hemorrhage with both lobectomy and segmental resection groups is about the same. It is of importance to note, however, that the incidence in the secondary resection group is almost three times higher than that in the primary resection group. The explanation lies in the fact that in
TABLE 3-ANALYSIS OF POSTOPERATIVE COMPLICATIONS
Complication
Type of Operation
1. Severe Hemorrhage with Shock
Lobectomy Segmental Resection Pneumonectomy
No. of Complication
4.4 3.3 10
5.2
Primary Resection Secondary Resection
7 5 12 12 0
Lobectomy Segmental Resection
3 5
2.;
Primary Resection Secondary Resection
8 0
2.5 0
Lobectomy Segmental Resection
5 3 8 6 2
3.7 1.6
Total Primary Resection Secondary Resection 2. Poor Re-expansion of Lung Requiring Corrective Thoracoplasty
3. Bronchopleural Fistula
4. Failure of Conversion of Positive Sputum
Lobectomy Segmental Resection Total
Total Primary Resection Secondary Resection 5. Infection of Pleural Cavity and Chest Wound
Lobectomy Segmental Resection Pneumonectomy Primary Resection Secondary Resection
Incidence of Total Complications According to Types of Operation:
Per cent
6 6 1 13 9 4
Lobectomy Segmental Resection Pneumonectomy Wedge Excision Lobectomy plus local Excision Primary Resection Secondarv Resection
Total 135 183 10 29
7
321 43
2.8 9.5
2.7 3.7
0 2.4
1.5 .5
1 1 J 3
0.7 0.5 10
1
0.3 4.6
2 22 20 2 0
16.4 10.8 20
0 36
0 10.8
8
19.0
0
196
Diseases of the Chest
MORGAN K. C. LU
most patients with secondary resection, previous artificial pneumothorax had been employed which increased the risk of postoperative hemorrhage as a result of extensive division of formative pleural adhesions.
2. Poor He-expansion of Lung Requiring Corrective Thoracoplasty There were 12 patients who required corrective thoracoplasty some six weeks after resection because of poor re-expansion of the remaining lung. All recovered fully. The contributing factors responsible for poor re-expansion of lung are: (1) poor expansion of the remaining anterior segment or the lingular segment following upper lobe segmental resection, (2) delayed pleural effusion or oozing of blood after removal of the intercostal tubes on the third or fourth postoperative day, and (3) small air pocket in the upper pleural cavity as a result of minor alveolar air leak. In addition to these 12 patients, there were 17 who had incomplete re-expansion of lung due to minor air leak or retention of pleural fluid, but all recovered with complete expansion of the remaining lung in the course of four to eight weeks.
under strict bed rest and use of appropriate antibiotics. Three patients with segmental resection had persistent air pocket in the upper pleural space and staining of sputum with blood for over three months. All recovered fully under the same regimen. Three patients who required corrective thoracoplasty alone or in combination with intrapleural closure of the fistula are now in satisfactory condition. The recovery rate is thus 100 per cent. However, it must be pointed out that in these eight patients, the fistulae were discovered during the postoperative period. Other patients with reactivated disease and potential fistula in the late follow-up period are not included here.
3. Bronchopleural Fistula The incidence of bronchopleural fistula is comparatively low in the present series. The recovery rate from it is also encouragingly high. Both the lobectomy and the segmental resection groups have approximately the same figures. Of the eight patients who suffered from this complication, two were diagnosed as having this condition on the basis of blood stained sputum and low grade fever present for four to six weeks after operation. Both recovered fully TABLE
4. Failure of Conversion of Positive Sputum There are eight patients who had failed to convert sputa to negative after resection beyond the postoperative period. In terms of the entire series of 360 patients, the incidence of this complication is 2.2 per cent. In terms of the 135 patients who presented positive sputa before operation, the incidence is 5.9 per cent. Of these eight, five still have persistent positive sputum and are under treatment and observation after cycloserine therapy, and another, who had a left upper lobectomy done, had the sputum converted after further operative procedures including corrective thoracoplasty and resection of the remaining lower lobe. One committed suicide in the hospital six months after operation while under cycloserine therapy. From the study of the pathologic findings in the resected lung specimens, bronchial disease and viability of the organisms in the lesions of the resected lung 4
Complication 1. 2. 3. 4. 5.
Number
Per cent
Severe Hemorrhage with Shock Poor Re-expansion of Lung Requiring Thoracoplasty Bronchopleural Fistula Failure of Sputum Conversion Infection of Pleura and Chest Wound
13 12 8 8 3
3.5 3.3 2.2 2.2 0.8
Total
44
12.1
Volume 41, No.2 February, 1962
197
RESECTION IN TUBERCULOSIS
tissue may be assumed to play an important role in perpetuating active disease in the remaining lung. It is significant to note that the incidence of failure of sputum conversion also tends to be higher with the secondary resection group than with the primary group--the ratio being 5 per cent against 1.5 per cent. 5. Infection of Pleura and Chest Wound
The incidence of both tuberculous and nontuberculous infection of the pleura and the chest wound is extremely low in the present series. Of the three patients who suffered from this complication, two belong to the secondary resection group, and both had tuberculous type of infection for which cycloserine therapy had been employed. The contributing factor responsible for the infection in these two patients had been persistent positive sputum with tubercle bacilli, which were resistant to all three of the standard drugs used preoperatively. The cause of infection in the third patient is postoperative hemorrhage with retention of blood in the pleural cavity. The organism responsible for the infection was Staphylococcus aureus. His condition was successfully remedied by repeated chest aspirations and chemotherapy. 6. Non-Chest Complications
Such complications are exceedingly rare. Only two instances were observed. (1) Postoperative thrombophlebitis of deep veins of leg-l (recovered); ( 2) Allergic purpura due to sensitivity to tetracycline1 (recovered) .
SUMMARY OF POSTOPERATIVE COMPLICATIONS
Table 4 gives the total incidence of all complications based on the entire series of 364 resections. It represents 12.1 per cent. ANALYSIS OF REACTIVATION FOLLOWING RESECTION
Table 5 gives a full account of the incidence of early and late reactivation of disease following various types of resection. Of the eight patients with this complication, three had reactivation develop during the postoperative period, and five others from six months to two years after operation. The incidence of reactivation based on the entire series of 364 resections is 2.2 per cent. The main causes of reactivation are thought to be inadequate preoperative chemotherapy, segmental resection with poor segmental cleavage, bronchopleural fistula, and clinically unrecognized bronchial disease. It is significant to note that the reactivation rate is distinctly higher with the secondary resection group of patients. Up-to-date follow-up revealed that five of these eight patients are in good condition with negative sputum after having had either secondary thoracoplasty or resection. The other threF are still under medical treatment and observation with unstable sputum status.:INDICATIONS FOR CORRECTIVE THORACOPLASTY
Of the 29 corrective thoracoplasties performed in this series, 12 were done for poor re-expansion of the remaining lung either
TABLE 5-ANALYSIS OF REACTIVATION ACCORDING TO TYPE 0 .." RESECTION
Types and Number of Operation Lobectomy (135) Segmental Resection (183) Pneumonectomy (10) Wedge Excision (29) Lobectomy plus Segmental Resection (7) Total 364 Resections Primary Resection (321) Secondary Resection (43)
Reactivation No.
Per cent
2
1.4
4 1 1
2.1 10 2.5
8 6 2
2.2
o
o
1.8
4.8
198
Diseases of
MORGAN K. C. LV
as a result of extensive pleural adhesion or postoperative oozing of blood hampering early re-expansion. The second main indication is for patients following resection of the left upper lobe, where the filling of the upper pleural space is absolutely essential. In three, corrective thoracoplasty was performed for reactivation of disease in the ipsilateral lung, and three others for treatment of bronchopleural fistula. Of the ten patients following pneumonectomy only one required corrective thoracoplasty. In the rest of this group the diseased lung was so much contracted and collapsed with traction of the mediastinum over to the affected side, the problem of space filling becomes less important. In two, corrective thoracoplasty was indicated because of recurrent hemoptyses after right upper lobectomy-potential case of bronchial disease or bronchopleural fistula. In the majority of cases, corrective thoracoplasty was performed from three to six weeks after resection. The final results of the 29 patients requiring corrective thoracoplasty are as follows: 1. Satisfactory with negative sputum 26. 2. Positive sputum 2. 3. Sputum converted negative after further resection 1. BACTERIOLOGIC STUDY OF RESECTED LUNG SPECIMENS
Bacteriologic studies of the resected lung specimens were carried out in 59 recently operated patients. Of these 59 specimens studied, positive culture was obtained in 19, with positive smear in 57. In 17 specimens, both culture and smear were positive for tubercle bacilli. It is interesting to note that in patients with positive sputum preoperatively, the resected s p e c i men s showed positive culture in over 50 per cent of cases, while in patients with negative sputum preoperatively, positive culture was obtained in 25 per cent. This expresses that sputum findings before operation furnish a good forecast of the viability of the organisms in the resected lung tissue. From analysis of the results of positive culture in re-
the Chest
sected lung specimens in relation to duration of preoperative chemotherapy, there is definite increase of culture positive for tubercle bacilli in specimens obtained from patients who had ( 1) no preoperative chemotherapy, (2) chemotherapy of less than three months, and (3 ) long-term chemotherapy of over three years. The percentage of positive culture in these three groups is 66.6 per cent. The lowest rate of positive culture was found in specimens from those patients who had preoperative chemotherapy for about 12 months, the figure being 15 per cent. These results seem to suggest that the optimal period of surgical intervention lies between six and 18 months, certainly within the first year of drug therapy. FINAL RESULTS
All except 15 patients have been followed and their present condition assessed. The number of deaths in the entire series is one, representing 0.28 per cent. Of the 359 patients living, 327 (91 per cent) are clinically well and have negative sputum, and 17 (4.7 per cent) have still active disease with or without positive sputum. Of these 17 patients, seven had lobectomy, seven segmental resection, two pneumonectomy, and one wedge excision. The following table gives the statistics of the final results: No. Total Patients .-----... ...--..-.-------.360 Postoperative Death _.- ... ... 0 Late Death (Committed Suicide) 1 327 Well with Negative Sputum Positive Sputum with or without X-ray Evidence of Disease __ . 9 _ 4 Unstable Sputum Status Partial Respiratory Cripple._. _._ 2 (Pneumonectomy Case) Potential Bronchopleural Fistula 2 No Follow-Up (Presumably Alive) ._ 15 Total Living ._ ..._. __ .. ... .359
Per cent 0.28 91 2.5
1.1
0.6
0.6 4.2 99.7
DISCUSSION
The results with resection in the present series permit us to conclude that it constitues a relatively safe form of treatment in the management of pulmonary tuberculosis. There was no postoperative death or late death due to tuberculosis. The only death occurred in a man who committed suicide
Volume 41, No.2 February, 1962
199
RESECTION IN TUBERCULOSIS
about six months after operation while on cycloserine therapy. The morbidity rates with lobectomy and segmental resection are approximately the same. This minor discrepancy is not unexpected because in most instances of lobectomy usually more extensive disease was dealt with; while in case of segmental resection usually a well selected group of patients with excellent general condition were treated, in whom the lesion in most instances represents a localized, inspissated nodular infiltration showing stable or retrogressive a p pea ran c e for some months under bed rest and chemotherapy. The morbidity rate with secondary resection is higher than that with primary resection, particularly when dealing with postoperative hemorrhage, infection, failure of sputum conversion, and reactivation. It is specially gratifying to note that the incidence of bronchopleural fistula is comparatively low for all types of resection, and its recovery rate is high. The follow-up statistics are also satisfactory. In spite of all these encouraging results, we must not believe that because we can perform an operative procedure with a high degree of technical skill and safety that it is the treatment of choice. The true measure of success of any plan of treatment for pulmonary tuberculosis is the return of the greatest number of patients to a normal and useful life with minimal loss of pulmonary function. The number of respiratory cripples must be kept at a minimal level. It is also particularly worthwhile to mention that the majority of patients with segmental resection could have been treated successfully by continuous medical treatment rather than by surgery. The results of analysis also point out that good results can be expected with any type of resection, provided the operation is the primary approach to the problem and is applied as soon as the ideal conditions have been achieved through a well coordinated program of treatment consisting of hospital care and intelligent use of antituberculosis drugs, and that all diseased foci are included well within the limit of the resected lung unit.
SUMMARY
This study represents a review of 360 patients subjected to 364 pulmonary resections between May, 1955 and September, 1959. The minimal follow-up for patients alive in January, 1960 is four months, the maximum being four years and six months. The majority of the patients have been followed in our chest clinics after discharge from the hospital. Approximately 91 per cent of the survivals are well and leading normal lives, 4.i per cent still have active disease with or without positive sputum. RESUl\fEN
Este estudio representa una revista de 360 enfermos a quienes se hiso reseccion pulmonar entre mayo de 1955 y sept. de 1959. EI minimo periodo de observacion para los en ferrnos que vivcn en enero de 1960 es de 4 meses v cl maximo es de cuatro anos y seis meses. La ~avoria de los enfermos fueron observados en nuestras clinicas de torax despues de salidos del hospital. Aproximadamente el 91 por ciento de las sobrevidas estan bien y haciendo vida normal y 4.7 por ciento tiene aun cnfermedad activa con 0 sin esputos positivos. RESUl\fE
L'auteur fait l'etude de 360 malades soumis a 364 resections pulmonaires, entremai1 955 et septembre 1959. Les malades en vie en janvier 1960 ont ete suivis pendant un minimum de quatre mois et un maximum de quatre ans et six mois. Les malades ont ete suivis en majorite dans les cliniques pulmonaires apres avoir quittc l'Hopital. A peu pres 91% des survivants sont en bonne sante et mencnt une vie norma le, et 4.7% ont encore une maladie active avec on sans expectoration positive. ZUSAM1\{EN.~ASSUNG
Diese Untersuchung beinhaltet cine Ubersicht von 360 Kranken, die zwischen Mai 1955 lind September 1959 mit 364 Lungenresektionen behandelt wurden. Die geringste Nachbeobachtungszeit fur im Januar 1960 am Leben befindliche Kranke betragt 4 Monate, die Hochstzeit 4 Jahre lind 6 Monate. Die Mehrzahl von Patienten wurden in unserer Thoraxambulanz nach der Entlassung aus dem Krankenhaus beobachtet. Ungefahr 91 % der Uberlebenden sind wohlauf und fuhren ein nornla les Leben und 4.7 % haben noch einen aktiven Befund mit oder ohne positivem Sputum.
K. C. Lu,
M.D., F.C.C.P.
Hong Kong
T
H IS STUDY REPRESENTS A REVIEW OF
360 tuberculous patients subjected to 364 pulmonary resections between May, 1955 and September, 1960. All the patients with the exception of 26, who were discovered to have isolated nodular opacity in the lung by chest survey and presented negative sputum status, had been treated in a well-coordinated program consisting of bed rest and antituberculosis chemotherapy. The decision to operate on these patients was, in the majority of cases, reached at chest conferences. The duration of postoperative convalescence in hospital varies from four to six months, as determined by the progress of the individual case. The period of postoperative chemotherapy consists of a minimum of 16 months, and it could be extended to two years or more as the condition of the individual patient may require. The minimal follow-up for the patients alive in January, 1960 was four months, the maximum being four years and six months. The postoperative period consists of an arbitrary period of three months following operation. The three standard antituberculosis drugs employed here are streptomycin, isoniazid and paraaminosalicylic acid. GENERAL STATISTICS
The general statistics, including sex, age, race, types of resection, preoperative chemotherapy, and preoperative sputum status, are presented in Table 1. Note the preponderance of segmental resection in the whole series. This indicates simply that a large group of patients belong to the well-selected group for resectional surgery. In most instances, the excision of the apical segment or the apico-posterior segments of the upper lobe was carried out. *From the Department of Surgery, Queen Mary Hospital, Hong Kong.
In a few occasions on the left side tri-segmental resection of the ~pper lobe with the preservation of the lingular segment was performed. In seven patients, segmental resection was used in addition to lobectomy. This group consists mainly of the combination of upper lobectomy and resection of the superior segment of the lower lobe. In 29 who had wedge excision, the nature of the lesion was usually a well-encapsulated, peripherally situated nodular opacity varying from 2 to 3 ern. in diameter. Of the entire series of 364 resections, 321 were primary and 43 were secondary resections following previous collapse therapy, or ipsilateral or contralateral resection. SPECIFIC INDICATIONS FOR RESECTION
The specific indications for resection are listed in Table 2. There are many patients who, listed under the category of diffuse or localized, dense residual infiltrations with or without cavity after chemotherapy, could have been good candidates for thoracoplasty, but resection was elected as the procedure of choice. With our gain in experience dealing with resectional surgery in the last five years, the indications for segmental resection are rapidly extending to include quite a large group with localized target focus of infiltrations remaining after treatment with bed rest and chemotherapy. Other well-selected cases SlJfh as those with large isolated nodular opacity, lobar atelectasis, chronic fibrotic cavitary lesion, tension cavity, and cavities in the superior segment of the lower lobe have met most of the essential criteria used in accepting patients for resection. In the group listed under the category of thoracoplasty failure, we believe that resection is the procedure of choice rather than revision thoracoplasty, as the underlying pathologic cause for the 193
194
Diseases of the Chest
MORGAN K. C. LU
TABLE I-GENERAL STATISTICS Pulmonary Resection for Tuberculosis-May, 1955 to September, 1959 Total Resections-364 Total Patients -360 Operations Lobectomy
Segmental Resection
135
183
Wedge Excision
~bectomy Plus Segmental Resection
Pneumonectomy
7
10
29
Previous Treatment: (A) No Previous Treatment (Primary Resection) .. .._._ .. .. .. .. .321 (B) Previous Collapse Therapy -. .. -- -- . 39 Ipsilateral Pneumothorax ..----..----.----. '--'-..--- - ---"---' .--..----. - ----..--.----.--- 20 Ipsilateral Phrenic Crush and Pneumoperitoneum.-.-_ ..__ ._.._.._ __ ._ _ --_ __ ..__ ._ 14 - ---- ..__._.. .. . -.. .._ . 3 Ipsilateral Thoracoplasty .--.--..---Ipsilateral Extrafascial Polythene Ball ..---_ __ ..__ .-.--- --.-.--..---_ .. .__ .----_.. 1 Contralateral Thoracoplasty - -------------------- ---- --.--------- --- -.----..---- 1 (C) Previous Resection ..---- ----..------ ----.----..----..----. '--.--.---- --------------..---- 4 _ e • • _ . __ • • • • • _ • • • • • •
Sex Male Female
No. 274
86
Races Chinese White Indian Portuguese
Preoperative Chemotherapy: )10 Chemotherapy Chemotherapy of three men ths to over two yean
No.
Age
351
8 to 20 years 21 to 40 yean 41 to 55 years
4 3 2 No. 26
••
••.••••
No. 21 291
Per cent 6
48
13
81
Preoperative Sputum Status: Positive (by Smear or Culture) Negative (by Smear and Culture)
No. 135 225
334
persistent positive sputum is either bronchial disease or residual cavity, which could hardly be closed by further collapse therapy. In the 13 patients with bronchiectasis, the tuberculous nature of the bronchial lesion was only known in less than half of the cases prior to pathologic examination of the resected lung specimens. Pneumonectomy was the operation of choice in ten patients, who suffered from extensive uni-
lateral disease. In one patient with chronic pleurisy and lesion in a collapsed upper lobe, decortication plus segmental resection were successfully performed. There are four patients with secondary resection. ANALYSIS OF POSTOPERATIVE COMPLICATIONS
Table 3 gives a full statistical account of the postoperative complications for the en-
TABLE 2-SPECIFIC INDICATIONS Radiologic Status 1. Diffuse or Localized, Dense Infiltration in Upper Lobe with or without Cavity after Chemotherapy (Mainly Apico-Posterior Segments) 2. Isolated Nodular Opacity 3. Lobar Atelectasis 4. Fibrotic Cavitary Lesion 5. Tension Cavity 6. Lower Lobe Disease 7. Bronchiectalis 8. Thoracoplasty Failure 9. Extensive lJ nilateral Disease 10. Chronic Pleurisy with Collapsed Upper Lobe (Decortication plus Resection) 11. Secondary Resection for Ipsilateral Reactivation 12. Secondary Resection for Contralateral Disease
No.
Per cent
216
60
58 16 31 1 10 13 4 10 1
16
3 1
4.3 8.4 0.27 2.7 3.4 1.1
2.7 0.27
0.8 0.27
Volume 41, No.2 February, 1962
195
RESECTION IN TUBERCULOSIS
tire group of patients subjected to various types of resection. In the last column of the same table the complete figures of incidence of all types of complication are put together according to the type of resection. 1. Severe Postoperative Hemorrhage
There were 13 who had a total blood loss of more than 1000 cc. during the first 24 to 48 hours after operation, and exhibited symptoms and signs of peripheral vascular failure. The main cause of hemorrhage is not easily assessed, and the bleeding was usually of slow, prolonged oozing type. In most instances, the blood had no tendency to form clots and drained freely
from the pleural cavity into the bedside drainage bottle. The question of fibrinolysis was considered, but we had not undertaken special investigations into the matter. All the 13 patients except one, who came down with partially collapsed lung and reactivation of disease in the latter course of the postoperative period, recovered fully without further complication. The incidence of hemorrhage with both lobectomy and segmental resection groups is about the same. It is of importance to note, however, that the incidence in the secondary resection group is almost three times higher than that in the primary resection group. The explanation lies in the fact that in
TABLE 3-ANALYSIS OF POSTOPERATIVE COMPLICATIONS
Complication
Type of Operation
1. Severe Hemorrhage with Shock
Lobectomy Segmental Resection Pneumonectomy
No. of Complication
4.4 3.3 10
5.2
Primary Resection Secondary Resection
7 5 12 12 0
Lobectomy Segmental Resection
3 5
2.;
Primary Resection Secondary Resection
8 0
2.5 0
Lobectomy Segmental Resection
5 3 8 6 2
3.7 1.6
Total Primary Resection Secondary Resection 2. Poor Re-expansion of Lung Requiring Corrective Thoracoplasty
3. Bronchopleural Fistula
4. Failure of Conversion of Positive Sputum
Lobectomy Segmental Resection Total
Total Primary Resection Secondary Resection 5. Infection of Pleural Cavity and Chest Wound
Lobectomy Segmental Resection Pneumonectomy Primary Resection Secondary Resection
Incidence of Total Complications According to Types of Operation:
Per cent
6 6 1 13 9 4
Lobectomy Segmental Resection Pneumonectomy Wedge Excision Lobectomy plus local Excision Primary Resection Secondarv Resection
Total 135 183 10 29
7
321 43
2.8 9.5
2.7 3.7
0 2.4
1.5 .5
1 1 J 3
0.7 0.5 10
1
0.3 4.6
2 22 20 2 0
16.4 10.8 20
0 36
0 10.8
8
19.0
0
196
Diseases of the Chest
MORGAN K. C. LU
most patients with secondary resection, previous artificial pneumothorax had been employed which increased the risk of postoperative hemorrhage as a result of extensive division of formative pleural adhesions.
2. Poor He-expansion of Lung Requiring Corrective Thoracoplasty There were 12 patients who required corrective thoracoplasty some six weeks after resection because of poor re-expansion of the remaining lung. All recovered fully. The contributing factors responsible for poor re-expansion of lung are: (1) poor expansion of the remaining anterior segment or the lingular segment following upper lobe segmental resection, (2) delayed pleural effusion or oozing of blood after removal of the intercostal tubes on the third or fourth postoperative day, and (3) small air pocket in the upper pleural cavity as a result of minor alveolar air leak. In addition to these 12 patients, there were 17 who had incomplete re-expansion of lung due to minor air leak or retention of pleural fluid, but all recovered with complete expansion of the remaining lung in the course of four to eight weeks.
under strict bed rest and use of appropriate antibiotics. Three patients with segmental resection had persistent air pocket in the upper pleural space and staining of sputum with blood for over three months. All recovered fully under the same regimen. Three patients who required corrective thoracoplasty alone or in combination with intrapleural closure of the fistula are now in satisfactory condition. The recovery rate is thus 100 per cent. However, it must be pointed out that in these eight patients, the fistulae were discovered during the postoperative period. Other patients with reactivated disease and potential fistula in the late follow-up period are not included here.
3. Bronchopleural Fistula The incidence of bronchopleural fistula is comparatively low in the present series. The recovery rate from it is also encouragingly high. Both the lobectomy and the segmental resection groups have approximately the same figures. Of the eight patients who suffered from this complication, two were diagnosed as having this condition on the basis of blood stained sputum and low grade fever present for four to six weeks after operation. Both recovered fully TABLE
4. Failure of Conversion of Positive Sputum There are eight patients who had failed to convert sputa to negative after resection beyond the postoperative period. In terms of the entire series of 360 patients, the incidence of this complication is 2.2 per cent. In terms of the 135 patients who presented positive sputa before operation, the incidence is 5.9 per cent. Of these eight, five still have persistent positive sputum and are under treatment and observation after cycloserine therapy, and another, who had a left upper lobectomy done, had the sputum converted after further operative procedures including corrective thoracoplasty and resection of the remaining lower lobe. One committed suicide in the hospital six months after operation while under cycloserine therapy. From the study of the pathologic findings in the resected lung specimens, bronchial disease and viability of the organisms in the lesions of the resected lung 4
Complication 1. 2. 3. 4. 5.
Number
Per cent
Severe Hemorrhage with Shock Poor Re-expansion of Lung Requiring Thoracoplasty Bronchopleural Fistula Failure of Sputum Conversion Infection of Pleura and Chest Wound
13 12 8 8 3
3.5 3.3 2.2 2.2 0.8
Total
44
12.1
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RESECTION IN TUBERCULOSIS
tissue may be assumed to play an important role in perpetuating active disease in the remaining lung. It is significant to note that the incidence of failure of sputum conversion also tends to be higher with the secondary resection group than with the primary group--the ratio being 5 per cent against 1.5 per cent. 5. Infection of Pleura and Chest Wound
The incidence of both tuberculous and nontuberculous infection of the pleura and the chest wound is extremely low in the present series. Of the three patients who suffered from this complication, two belong to the secondary resection group, and both had tuberculous type of infection for which cycloserine therapy had been employed. The contributing factor responsible for the infection in these two patients had been persistent positive sputum with tubercle bacilli, which were resistant to all three of the standard drugs used preoperatively. The cause of infection in the third patient is postoperative hemorrhage with retention of blood in the pleural cavity. The organism responsible for the infection was Staphylococcus aureus. His condition was successfully remedied by repeated chest aspirations and chemotherapy. 6. Non-Chest Complications
Such complications are exceedingly rare. Only two instances were observed. (1) Postoperative thrombophlebitis of deep veins of leg-l (recovered); ( 2) Allergic purpura due to sensitivity to tetracycline1 (recovered) .
SUMMARY OF POSTOPERATIVE COMPLICATIONS
Table 4 gives the total incidence of all complications based on the entire series of 364 resections. It represents 12.1 per cent. ANALYSIS OF REACTIVATION FOLLOWING RESECTION
Table 5 gives a full account of the incidence of early and late reactivation of disease following various types of resection. Of the eight patients with this complication, three had reactivation develop during the postoperative period, and five others from six months to two years after operation. The incidence of reactivation based on the entire series of 364 resections is 2.2 per cent. The main causes of reactivation are thought to be inadequate preoperative chemotherapy, segmental resection with poor segmental cleavage, bronchopleural fistula, and clinically unrecognized bronchial disease. It is significant to note that the reactivation rate is distinctly higher with the secondary resection group of patients. Up-to-date follow-up revealed that five of these eight patients are in good condition with negative sputum after having had either secondary thoracoplasty or resection. The other threF are still under medical treatment and observation with unstable sputum status.:INDICATIONS FOR CORRECTIVE THORACOPLASTY
Of the 29 corrective thoracoplasties performed in this series, 12 were done for poor re-expansion of the remaining lung either
TABLE 5-ANALYSIS OF REACTIVATION ACCORDING TO TYPE 0 .." RESECTION
Types and Number of Operation Lobectomy (135) Segmental Resection (183) Pneumonectomy (10) Wedge Excision (29) Lobectomy plus Segmental Resection (7) Total 364 Resections Primary Resection (321) Secondary Resection (43)
Reactivation No.
Per cent
2
1.4
4 1 1
2.1 10 2.5
8 6 2
2.2
o
o
1.8
4.8
198
Diseases of
MORGAN K. C. LV
as a result of extensive pleural adhesion or postoperative oozing of blood hampering early re-expansion. The second main indication is for patients following resection of the left upper lobe, where the filling of the upper pleural space is absolutely essential. In three, corrective thoracoplasty was performed for reactivation of disease in the ipsilateral lung, and three others for treatment of bronchopleural fistula. Of the ten patients following pneumonectomy only one required corrective thoracoplasty. In the rest of this group the diseased lung was so much contracted and collapsed with traction of the mediastinum over to the affected side, the problem of space filling becomes less important. In two, corrective thoracoplasty was indicated because of recurrent hemoptyses after right upper lobectomy-potential case of bronchial disease or bronchopleural fistula. In the majority of cases, corrective thoracoplasty was performed from three to six weeks after resection. The final results of the 29 patients requiring corrective thoracoplasty are as follows: 1. Satisfactory with negative sputum 26. 2. Positive sputum 2. 3. Sputum converted negative after further resection 1. BACTERIOLOGIC STUDY OF RESECTED LUNG SPECIMENS
Bacteriologic studies of the resected lung specimens were carried out in 59 recently operated patients. Of these 59 specimens studied, positive culture was obtained in 19, with positive smear in 57. In 17 specimens, both culture and smear were positive for tubercle bacilli. It is interesting to note that in patients with positive sputum preoperatively, the resected s p e c i men s showed positive culture in over 50 per cent of cases, while in patients with negative sputum preoperatively, positive culture was obtained in 25 per cent. This expresses that sputum findings before operation furnish a good forecast of the viability of the organisms in the resected lung tissue. From analysis of the results of positive culture in re-
the Chest
sected lung specimens in relation to duration of preoperative chemotherapy, there is definite increase of culture positive for tubercle bacilli in specimens obtained from patients who had ( 1) no preoperative chemotherapy, (2) chemotherapy of less than three months, and (3 ) long-term chemotherapy of over three years. The percentage of positive culture in these three groups is 66.6 per cent. The lowest rate of positive culture was found in specimens from those patients who had preoperative chemotherapy for about 12 months, the figure being 15 per cent. These results seem to suggest that the optimal period of surgical intervention lies between six and 18 months, certainly within the first year of drug therapy. FINAL RESULTS
All except 15 patients have been followed and their present condition assessed. The number of deaths in the entire series is one, representing 0.28 per cent. Of the 359 patients living, 327 (91 per cent) are clinically well and have negative sputum, and 17 (4.7 per cent) have still active disease with or without positive sputum. Of these 17 patients, seven had lobectomy, seven segmental resection, two pneumonectomy, and one wedge excision. The following table gives the statistics of the final results: No. Total Patients .-----... ...--..-.-------.360 Postoperative Death _.- ... ... 0 Late Death (Committed Suicide) 1 327 Well with Negative Sputum Positive Sputum with or without X-ray Evidence of Disease __ . 9 _ 4 Unstable Sputum Status Partial Respiratory Cripple._. _._ 2 (Pneumonectomy Case) Potential Bronchopleural Fistula 2 No Follow-Up (Presumably Alive) ._ 15 Total Living ._ ..._. __ .. ... .359
Per cent 0.28 91 2.5
1.1
0.6
0.6 4.2 99.7
DISCUSSION
The results with resection in the present series permit us to conclude that it constitues a relatively safe form of treatment in the management of pulmonary tuberculosis. There was no postoperative death or late death due to tuberculosis. The only death occurred in a man who committed suicide
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RESECTION IN TUBERCULOSIS
about six months after operation while on cycloserine therapy. The morbidity rates with lobectomy and segmental resection are approximately the same. This minor discrepancy is not unexpected because in most instances of lobectomy usually more extensive disease was dealt with; while in case of segmental resection usually a well selected group of patients with excellent general condition were treated, in whom the lesion in most instances represents a localized, inspissated nodular infiltration showing stable or retrogressive a p pea ran c e for some months under bed rest and chemotherapy. The morbidity rate with secondary resection is higher than that with primary resection, particularly when dealing with postoperative hemorrhage, infection, failure of sputum conversion, and reactivation. It is specially gratifying to note that the incidence of bronchopleural fistula is comparatively low for all types of resection, and its recovery rate is high. The follow-up statistics are also satisfactory. In spite of all these encouraging results, we must not believe that because we can perform an operative procedure with a high degree of technical skill and safety that it is the treatment of choice. The true measure of success of any plan of treatment for pulmonary tuberculosis is the return of the greatest number of patients to a normal and useful life with minimal loss of pulmonary function. The number of respiratory cripples must be kept at a minimal level. It is also particularly worthwhile to mention that the majority of patients with segmental resection could have been treated successfully by continuous medical treatment rather than by surgery. The results of analysis also point out that good results can be expected with any type of resection, provided the operation is the primary approach to the problem and is applied as soon as the ideal conditions have been achieved through a well coordinated program of treatment consisting of hospital care and intelligent use of antituberculosis drugs, and that all diseased foci are included well within the limit of the resected lung unit.
SUMMARY
This study represents a review of 360 patients subjected to 364 pulmonary resections between May, 1955 and September, 1959. The minimal follow-up for patients alive in January, 1960 is four months, the maximum being four years and six months. The majority of the patients have been followed in our chest clinics after discharge from the hospital. Approximately 91 per cent of the survivals are well and leading normal lives, 4.i per cent still have active disease with or without positive sputum. RESUl\fEN
Este estudio representa una revista de 360 enfermos a quienes se hiso reseccion pulmonar entre mayo de 1955 y sept. de 1959. EI minimo periodo de observacion para los en ferrnos que vivcn en enero de 1960 es de 4 meses v cl maximo es de cuatro anos y seis meses. La ~avoria de los enfermos fueron observados en nuestras clinicas de torax despues de salidos del hospital. Aproximadamente el 91 por ciento de las sobrevidas estan bien y haciendo vida normal y 4.7 por ciento tiene aun cnfermedad activa con 0 sin esputos positivos. RESUl\fE
L'auteur fait l'etude de 360 malades soumis a 364 resections pulmonaires, entremai1 955 et septembre 1959. Les malades en vie en janvier 1960 ont ete suivis pendant un minimum de quatre mois et un maximum de quatre ans et six mois. Les malades ont ete suivis en majorite dans les cliniques pulmonaires apres avoir quittc l'Hopital. A peu pres 91% des survivants sont en bonne sante et mencnt une vie norma le, et 4.7% ont encore une maladie active avec on sans expectoration positive. ZUSAM1\{EN.~ASSUNG
Diese Untersuchung beinhaltet cine Ubersicht von 360 Kranken, die zwischen Mai 1955 lind September 1959 mit 364 Lungenresektionen behandelt wurden. Die geringste Nachbeobachtungszeit fur im Januar 1960 am Leben befindliche Kranke betragt 4 Monate, die Hochstzeit 4 Jahre lind 6 Monate. Die Mehrzahl von Patienten wurden in unserer Thoraxambulanz nach der Entlassung aus dem Krankenhaus beobachtet. Ungefahr 91 % der Uberlebenden sind wohlauf und fuhren ein nornla les Leben und 4.7 % haben noch einen aktiven Befund mit oder ohne positivem Sputum.