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Surgical Diseases of the Lung
Surgical Diseases of the Lung ALFRED GOLDMAN, M.D. *
IN THE broad spectrum of pulmonary diseases, thoracic surgery is a diagnostic and therapeutic tool to be utilized in selected cases (Table 1). It follows that any given lesion of the lung may require a surgical procedure during the course of medical management. Such a concept implies close collaboration and consultation not only between the physician and surgeon but also with the ancillary specialists, particularly endoscopist, pathologist, otolaryngologist, bacteriologist and radiologist. Fortunately, only a small percentage of cases are true emergencies (i.e., thoracic injuries) so there is time to accumulate clinical data for complete evaluation of the patient in reference to the indications for surgical treatment as well as the type of operation to be performed. Nevertheless, the factor of timing surgical intervention should be given serious consideration lest either undue haste or delay mitigate against the best possible results. PULMONARY TUBERCULOSIS
In general, the incidence of patients requiring surgical treatment has decreased since the widespread use of effective chemotherapy during the past decade. It is well to keep in mind that chemotherapy! has made possible the safe introduction of resectional therapy15, 20 and that it is too early to be certain whether the recent trend toward less surgery in pulmonary tuberculosis will continue. Already large numbers of patients with sputums rendered negative by chemotherapy alone are returning after a period of months with positive sputums. 17 Many of these are now being considered for surgical help. PullIlonary Resection
Modern surgical treatment of pulmonary tuberculosis utilizes pulmonary resection as its major tool. This has evolved because pulmonary From the Thoracic Surgical Services, Cedars of Lebanon Ilospital, LotJ Angeles, California, and City of Hope Medical Center, Duarte, Californ'£a.
* Senior Attending Surgeon, Cedars of Lebanon Hospital; Co-Chairman, Department of Surgery and Surgeon-in-Chief, Thorac'£c and Cardiac Surgery, City of Hope Medical Center. 1055
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1056 Table 1 SURGICAL DISEASES OF THE LUNG
1. Tuberculosis a. Cavities b. Bronchostenosis c. Bronchiectasis d. Failure of collapse therapy e. Lower lobe disease f. Persistent positive sputum g. Destroyed lung h. Tuberculoma i. Bronchopleural cutaneous fistula j. Empyema k. Chondritis and osteomylitis of ribs and sternum 1. Hemoptysis 2. Primary neoplasms a. Benign b. Potentially malignant c. Malignant d. Metastatic 3. Fungus disease a. Coccidioidomycosis b. Blastomycosis c. Histoplasmosis d. Aspergillosis c. Nocardiosis f. Cryptococcosis 4-. Traumatic injury a. Continued bleeding b. Hemothorax (clotted) c. Captive lung d. Bronchial, tracheal, or vascular laceration e. Subcutaneous emphysema f. Tension pneumothorax 5. N ontuberculous suppurations a. Gangrene b. Bronchiectasis c. Lung abscess d. Mucoid bronchial impaction e. Lipoid pneumonia f. Foreign body, bronchus g. Bronchial obstruction with endobronchial disease and lymph node compression (middle lobe syndrome) 6. Coin lesions (of the lung) 7. Vascular lesions a. Aberrant systemic artery of the lung with sequestration b. Aneurysm c. Arteriovenous fistula d. Hemangioma 8. Pulmonary cysts a. Congenital b. Acquired (1) Cystic bronchiectasis (2) Epithelized cavities (3) Pneumocele (4) Bullae (5) "Disappearing" lung (6) Cysts associated with neoplasms (7) Parasitic cysts (hydatid)
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resection removes the lesion, does not result in deformity of the chest wall, is selective, does not unduly decrease pulmonary function, and results in more permanent conversion of the sputum. 8 Clinical indications are: 1. Cavities a. Thick-walled cavities b. Large or giant cavities c. Tension cavities d. Hemorrhaging cavities c. Lower lobe cavities 2. Bronchostenosis 3. Tuberculoma 4. Destroyed lung or lobe 5. Thoracoplasty failure 6. Bronchiectasis 7. Residual localized disease after prolonged chemotherapy
1:'he types of resectional therapy consist of subsegmentectomy, segmentectomy, lobectomy, pneumonectomy and pleural penumonectomy.5. 7,21 SUBSEGMENTECTOMY
Subsegmentectomy is indicated when the lesion is small, usually less than 4 cm., and located subpleurally. This procedure is most often employed as an adjunct to resection of a larger portion of the lung. It should be remembered that tuberculosis of the lung is usually bilateral but not often active bilaterally and that minor nodular disease may safely be left after resection of the active disease. SEGMENTECTOMY
Modern surgical treatment of tuberculosis utilizes mainly segmental resection and lobectomy in its attack on the disease. The size of the necrotic lesion, its location, and the absence of extensive exudative or caseous pneumonic disease as well as the duration of the lesion are important considerations in the indications for segmentectomy. Chamberlain3 has summarized the indications as follows: "The ideal indication for segmental resection is the fibrocaseous lesion with or without a cavity and devoid of an exudative element. The focus should be of such size and duration that mature medical opinion is doubtful of the patient's future security." Preparation of the Patient. Localization of the lesion and determination of its size and character are best studied with the aid of body section radiography, especially lateral views. Preliminary tuberculous drug therapy is the sine qua non for success in this operation because morbidity and mortality are reduced by preparation of the patient. Generally speaking, "triple treatment" consisting of streptomycin, 1 gram three times weekly, intramuscularly, para-aminosalicylic acid, 12 grams
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daily, and isonicotinic acid hydrazide, 300 to 1000 mg. daily are given preoperatively for months or years until the tubercle bacilli in the sputum or gastric secretions can either no longer be detected or appear very rarely in monthly examinations. Prolonged chemotherapy in the face of resistant organisms is to be avoided. The patient with resistant tubercle bacilli should be studied for sensitivity to viomycin (dosage 2 to 3 grams twice weekly, intramuscularly) oxytetracycline (dosage 2 grams daily), pyrazinamide (dosage 3 grams daily), and kanamycin (dosage 0.5 gram four times daily, intramuscularly). Since these latter drugs may have specific toxicity, thorough knowledge of their toxic effects is a prerequisite to their use. Less toxic is Dipasic (Panray), 10 mg. per kilogram of body weight. Postoperative Management. Postoperatively the chemotherapy is continued for months or years until in the judgment of the physician it is safe to stop the treatment. The time for discontinuing chemotherapy is based upon experience plus an evaluation of the clinical status of the patient particularly through bacteriological examination of sputa and gastric secretions, x-ray films of the chest, and the elimination of toxicity, cough and expectoration. A period of observation with ambulation and work is often necessary. M orbidity, Mortality and Results. Mortality from this operation should not exceed 3 to 5 per cent and good results with conversion of sputum can be expected in 90 to 95 per cent of selected patients. Morbidity consists of bronchopleural fistula (approximately 10 per cent), empyema (approximately 5 per cent) and spread of disease (approximately 3 per cent). The bronchopleural fistulas are generally small and readily controlled in the majority of instances through closed or open drainage of the pleural cavity plus tailoring thoracoplasty as indicated. Rarely, lobectomy may be required. For encapsulated tuberculous empyema with bronchopleural fistula, we prefer drainage by the Eloesser skin flap technique. Spreads are most often amenable to continued chemotherapy plus prolonged bed rest. In such instances, larger doses of isonicotinic acid hydrazide, up to 1000 mg. daily, may be effective. LOBECTOMY
I ndications are: Large or giant cavities Lobar bronchostenosis Segrpental resection failures Thoracoplasty failures when the remaining lobes are so little affected as to be safe to leave 5. Tuberculous bronchiectasis with lobar localization 6. Uncontrolled lower lobe disease involving more than one segment
1. 2. 3. 4.
Lobectomy vs. Segmentectomy for Upper Lobe Disease. Since tuberculosis is primarily an upper lobe disease and because the right upper lobe is
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particularly amenable to resection without exposing fractured areas of leaking alveoli from the middle and lower lobes, whenever the disease is associated with two segments of the right upper lobe we prefer lobectomy to segmentectomy. In the left upper lobe because of the anatomical relationshipll of the posterior-apical segment, segmentectomy is frequently preferred to lobectomy. In this connection, it should be realized that the lingula4 has no fissure separating it from the left upper lobe so that there is no advantage in left upper lobectomy without lingulectomy from the standpoint of fracturing through the air sacs contiguous with the left upper lobe lingula. The morbidity associated with segmentectomy has influenced us to perform lobectomy rather than segmentectomy in certain borderline cases. Postoperative Care and Results. The postsurgical care of patients with lobectomy usually requires three to six months of bed rest and a total of six to nine months for further rehabilitation. When the open lesion has been removed by lobectomy, sputum conversion of 90 to 95 per cent can be expected. PNEUMONECTOMY
Pneumonectomy is rarely indicated today since the majority of patients are discovered at an earlier stage of their disease. In bilateral disease, pneumonectomy is still less frequently indicated. The major indication is a destroyed lung and, secondly, when the stem bronchus is markedly stenotic. The contralateral lung should be free of disease or disease should be minimal. Pulmonary function should be adequate to maintain life and not result in the production of a respiratory cripple. Mortality from pneumonectomy is approximately 10 per cent. Tuberculous empyema is a very serious postoperative complication of pneumonectomy. Diminution of the pleural space on the resected side is desirable as a preventive measure and this may be accomplished by resection of the phrenic nerve during pneumonectomy. Tailoring by partial thoracoplasty may also be indicated. PLEURAL PNEUMONECTOMY
This operation is reserved for the treatment of tuberculous empyema with underlying destroyed lung. In those patients who have had prolonged pneumothorax treatment and whose lungs cannot be restored to function or expansion and the pleura is infected, pleural pneumonectomy may be indicated. The mortality is approximately 10 per cent and the end results are good to excellent in approximately 90 per cent of the remainder. Collapse Therapy Pneumothorax. Pneumothorax is rarely indicated in the modern management of pulmonary tuberculosis. The same may be said of pneumo-
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peritoneum. In most centers these procedures are losing their vogue primarily because they require years of treatment and do not so often lead to complete conversion of sputum or complete rehabilitation of the patient as does resectional therapy. Loss of pulmonary function cannot be controlled because of the unpredictable behavior of the bronchial factor,2 and pleural complications from pneumothorax have a high incidence. Besides, the residual disease is always present since it is not removed. Pneumoperitoneum. Repeated fillings of air into the peritoneal cavity avoid pleural complications. Their widespread use is controversial. Staged Thoracoplasty. A lesser sputum conversion rate of approximately 70 per cent with a slow conversion, pain, predisposition to spread, and deformity of the chest wall plus the necessity for multiple operations have been largely responsible for the discontinuance of the standard staged posterior thoracoplasty. In some clinics, thoracoplasty plus extrafascial dissection after the technique of Semb 18 is still popular. Carefully staged thoracoplasty in the older age group, with chemotherapy, may be considered the safest and simplest procedure to control that particular patient's disease. Deformity and painful chest wall are the major deterrent factors. Plombage. As a collapse measure, plombage with the aid of many kinds of foreign materials, such as Ivalon sponge, Lucite spheres, and paraffin, placed either in the extrapleural or extrafascial space with preservation of the ribs, in some instances by partial subperiosteal dissection so as to prevent deformity, has been utilized as a substitute for staged thoracoplasty. The advantages over thoracoplasty are: operation is done in one stage, and deformity of the chest wall is eliminated. In those centers not set up for pulmonary resection, plombage procedures are indicated particularly for young women of marital age in whom deformity of the chest wall is highly objectionable. '"fhe disadvantages are the use of a foreign material which may be associated with infection in future years, and the fact that pulmonary resection if required later is more difficult and the permanent conversion rate of the sputum is lower than is obtained by resection. Large cavities are not amenable to this type of collapse therapy both because the closure rate is relatively low and the complications of rupture of the cavity with infection of the plombage space are relatively high. CavernostOInY and Drainage of Cavity
The Monaldil4 technique for drainage of cavities requires meticulous care. Morbidity as regards pleural infection, chest wall sinuses, and failure of closure of the cavity is so frequent and the general drainage period so prolonged for months or years as to be a major deterrent in favor of other closed procedures when they will accomplish satisfactory results. In patients with giant cavities, external drainage of the cavity
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either by the Monaldi technique or open drainage of the cavity with removal of a portion of rib and roof of the cavity with insertion of a skin flap are indicated when no other method appears to be effective. Such drainages frequently require many months or years of daily dressings as well as secondary procedures such as application of pectoral muscle flaps inserted into the residual draining lung cavity in order to produce final closure of the chest wall. Decortication of the Lung
Indications are: 1. Nonexpansion of the lung following artificial pneumothorax 2. To aid in re-expanding residual lung during pulmonary resection 3. Encapsulated empyema associated with underlying lung not requiring resection or collapse 4. Captive lung associated with obliteration of a pneumothorax space by mediastinal and cardiac shift rather than by pulmonary re-expansion
N onexpansion of the Lung Following Artificial Pneumothorax. In general, decortication should not be employed for expanding any lung in which the tuberculous process may be reasonably expected to become active or is active at the time. In assessing the patient for decortication, he should be studied bronchoscopically for the presence or absence of significant bronchostenosis since bronchostenosis interferes with reexpansion of the lung. Pulmonary function may be studied by physiological testing and pulmonary circulation by angiography to make certain that chronic emphysematous changes have not occurred to such an extent that they will produce major symptoms and reactivation of tuberculosis after the lung is brought to re-expansion. In the immediate postoperative period, maintenance of a clean bronchial airway and suction in the pleural cavity to produce quick and permanent re-expansion of the lung are necessary features for success of the operation. Decortication During Pulmonary Resection; "Pleural Weaving." In many instances, chronic minimal pleural involvement is seen when the chest is opened for pulmonary resection. Over the lower lobes there is frequently found a delicate warp and woof of pleural adhesions which can be teased from the normal visceral pleura. When this separation has been completed, captive lung which had been folded in on itself reexpands under the influence of "bagging" by the anesthetist. The removal of this delicate pleural weaving is tedious and constitutes a decortication somewhat different from removal of visceral peel but is nonetheless necessary for success of the pulmonary resection. Encapsulated Empyema. The peel encompassing such encapsulated empyemas may be 1 or 2 cm. thick and involves not only the visceral but the parietal pleura. It may also be expedient to leave behind the parietal peel. Should the lung not expand satisfactorily during the post-
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operative period, selective thoracoplasty is useful to obliterate the pleural space. Captive Lung Without Pleural Empyemas or Pockets of Air. The indication for removal of the thick pleural peel in these patients is to relieve them of the symptoms from torsion of the heart and great vessels, such as tachycardia, dyspnea, thoracic discomfort, and pain. COCCIDIOIDOMYCOSIS
Coccidioidomycosis is on the increase, apparently as the result of movements of population, establishment of air fields in endemic areas and the heavy automobile and truck movements particularly in farming areas where the organism inhabits the soil. It appears to be spread in the dusts from the soil. The disease mimics tuberculosis in practically all its forms. Cotton6 cites the following indications for operation: 1. 2. 3. 4.
Giant cavity Secondarily infected cavities Check valve cavity Ruptured cavity (pleural effusion, spontaneous pneumothorax, cmpyenul, bronchopleural fistula, nonexpansion of lung) 5. Coccidioidomycoma 6. Continued and severe hemoptysis
Coccidioidal Cavities. It is not necessary to operate on the thin-walled, asymptomatic cavity of small or moderate size because the disease does not have the public health aspects of tuberculosis; and, since dissemination occurs in only one of 400 cases of infection with coccidioides of all types, the patient harboring such a cavity is in little danger. Giant cavities, larger than 5 cm., should be operated upon because of the danger of rupture and empyema and the high incidence of hemoptysis and secondary infection. Infected cavities, check valve cavities, and bleeding cavities produce toxicity and serious symptomatology which is rarely relieved except by resection. Ruptured cavities produce spontaneous pneumothorax, empyema, bronchopleural fistula and nonexpansile lung and so require relief of the collapse of the lung and drainage of the pleural space with decortication and closure of the bronchopleural fistula or resection of the cavity, as with tuberculosis. Preparation of Patients with Coccidioidomycosis for Operation. The acute phase of the disease should have passed. This generally takes approximately six months. Chemotherapy as for tuberculosis is not necessary but the ascertainment of bronchiectasis and localization of the cavity by endoscopic and radiological procedues is necessary. The general condition of the patient should be improved so that he can stand localized resection or lobectomy, as the case may be. Postoperatively the dissemination is negligible. A prolonged period of rehabilitation is not required. Early ambulation and return to work in approximately one month after uncomplicated surgical procedures are to be expected.
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COIN LESIONS OF THE LUNG
During the past ten years, it has become appreciated especially as a result of x-ray surveys in the military services and mass x-ray surveys for pulmonary tuberculosis that a relatively high number of lesions of varying sizes can be visualized in the asymptomatic stage. Approximately 3000 such lesions were discovered in the Los Angeles mass survey of 1,700,000 x-ray films. Such patients should be considered tumor suspects until proved otherwise. These lesions may present as round, so-called coin lesions, localized infiltrations in varying degrees of bronchial obstruction with atelectasis. A long list of diseases, of which mass survey lesions are a manifestation, has been reported by many observers. They include chronic abscesses, granuloma of unknown etiology, specific granulomas, tuberculoma, coccidioidomycoma, histoplasmoma, hydatid disease, pulmonary infarction, nonspecific pneumonitis, arteriovenous fistula of the lung, bronchial adenoma, fibroma, lipoma, hamartoma, pleural mesiothelioma, sarcoma and carcinoma (both primary and metastatic). According to Trimble,22 the major problem is not so much an exact diagnosis but the immediate and pressing question of whether or not this x-ray shadow represents carcinoma. Rigler16 has pointed out that carcinoma has an asymptomatic stage when it appears as a coin lesion in the x-ray. Characteristically, the "coin lesion" that is malignant may have a notch at its periphery. Such lesions are rarely calcified. A search should be made for all previous x-rays of the chest which the patient has had. A film one year old that is negative, especially that of a male over the age of 40 who is presently being investigated for a coin lesion, is highly indicative that the lesion is a new growth and probably carcinoma. Because pulmonary resection of such asymptomatic carcinomas has led to a higher five-year survival rate than in the ordinary run of surgical resections for carcinoma, it is important that definitive diagnosis be obtained before eliminating the prospect of carcinoma of the lung. This can usually be accomplished only by exploratory thoracotomy,6 albeit sputum examinations for tumor cells, fungi, and acid fast bacilli should be carried out. Bronchoscopy is especially indicated in patients with severe cough, as occasionally the "coin lesion" is a metastatic growth associated with a primary bronchogenic carcinoma invading the walls of the large bronchi. If the index of suspicion is low, bronchoscopy may be omitted, otherwise it is indicated in the preoperative studies. Other Diagnostic Procedures. It is rarely necessary to perform roentgenologic bone surveys, gastrointestinal x-ray series, or special investigations of the genitourinary tract in the patient with "coin lesion" because of the dearth of symptoms referable to these systems. Should symptoms be present, the special x-ray examinations indicated should be performed. Appropriate special laboratory examinations including those for tubercle bacilli, Bence-Jones protein in urine, tests for aglobulinemia such as the
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electrophoretic pattern of the serum, skin tests for coccidioides, blastomycosis, undulant fever and tuberculosis, cytologic examination of the sputum, examinations of the esophageal and gastric contents, complement fixation and agglutinin tests of the serum, guinea pig inoculation and culture of the sputum may on occasion yield confirmatory evidence when there is a high index of suspicion from the history, physical examination and routine radiological and clinical laboratory work-up. Because of the scarcity of positive results, however, we advise in general that the preoperative diagnostic work-up in those lesions with a high index of suspicion of neoplasm should include only (1) examination of the sputum for malignant cells and (2) skin tests for coccidioides, tuberculosis and histoplasmosis. A prolonged search by laboratory aids for a specific diagnosis is apt to lead to confusion and important loss of time which may mitigate against the benefits to be achieved by early exploratory thoracotomy. Exploratory Thoracotomy. In the noncalcific lesion, exploratory thoracotomy is indicated in all instances in which the general condition of the patient is not a contraindication and the suspicion of neoplasm exists. This operation has an extremely low morbidity and mortality rate, in the neighborhood of 1 per cent or less, and results in a positive diagnosis in almost all cases. A pathologist should always be present and available to make a frozen section diagnosis as well as diagnosis from the gross specimen submitted to him. The definitive surgical therapeutic procedure can then be carried out without the patient having to undergo a separate procedure. Significance of the Presence of Calcium. Some "coin lesions" contain radiopaque material and are usually called "calcific," thus indicating the higher probability of granuloma. Certain adenomas, particularly those of the mixed tumor variety, may develop osteoid tissue and even bone formation, carcinoma of the lung may arise in close proximity to old calcific foci of the lung, but the great majority of calcific lesions are granulomas and a high index of suspicion of this diagnosis may be achieved from the roentgenological study. The "coin lesion" should generally not be watched, but exceptions to this rule may be made if calcium is present, and the calcified lesion should be removed if it shows any sign of enlargement or if in the opinion of experienced observers the lesion is highly suggestive of neoplasm. The reason for this emphasis on the importance of exploratory thoracotomy for !'coin lesion" is based upon the finding in large series of patients so explored that approximately one-third of the lesions found were malignant. Patients are frequently referred to thoracic surgical clinics whose original x-rays one or two years before showed a "coin lesion" but whose present x-rays show a large inoperable cancer of the lung. This is truly a sad experience and warrants the dictum, !!coin lesions should not be watched."
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TUMORS OF THE LUNG
Benign and Potentially Malignant Lesions of the Lung
The benign lesions of the lung are fibroma, lipoma, hamartoma, myo.. blastoma and inflammatory polyps. The potentially malignant lesions, if not in fact actually malignant from the start of their growth, are primarily the bronchial adenomas. 9 The most important therapy for all these tumors is surgical excision, which may be accomplished by endoscopy, transpleural bronchotomy, ID or pulmonary resection, i.e., segmentectomy, pneumonectomy or lobectomy. While serious symptoms from bronchial obstruction and hemoptysis are associated with benign pulmonary tumors, the prognosis is excellent. Endoscopic Treatment. Tumors that arise in the stem, lobar or segmental bronchi may sometimes be removed through the bronchoscope provided they have a thin stalk or pedicle and lie relatively free in the lumen of the bronchus. All such accessible tumors should have a bronchoscopic biopsy. In many instances relief of bronchial obstruction can be obtained through aspiration of the dammed-up secretions distal to the obstructing tumor. Endoscopy, therefore, may be valuable in the preparation of the patient as well as in diagnosis. 13 • 19 However, 90 per cent of these tumors cannot be removed totally via the bronchoscope because of intramural or extramural extension of the tumor. Transpleural Bronchotomy. Benign tumors arising in the stem, lobar or segmental bronchi are especially amenable to local excision by transpleural bronchotomy. This procedure enables a thorough exploration of the pleural cavity and mediastinum for evidence of metastases and of irreversible lung destruction that may be caused by prolonged bronchial obstruction. Bronchography may demonstrate bronchiectasis distal to the tumor. Characteristically, the lung that has been obstructed has its bronchial tree full of dammed-up bronchial secretions which may be either purulent or mucoid. In some instances, the obstructed lung has been converted to a cystic bag. TECHNIQUE OF TRANSPLEURAL BRONCHOTOMY. ID After the chest is entered, the bronchus containing the tumor is thoroughly inspected in its outer aspect for evidence of extrabronchial portions of the tumor and involved lymph nodes. Biopsy material for frozen section may be obtained at this time. Guide sutures are placed in the bronchial wall, after which the bronchus is incised in the noninvolved area and the incision developed to delineate the characteristics of the surface of the tumor and its attachment at the bronchial wall. The tumor is then excised with the bronchial wall and the bronchus closed with interrupted silk sutures by a plastic technique which leaves an adequately ventilating lumen of the bronchus. In some instances, sleeve resection of the entire wall of the bronchus is necessary and in others only a portion of the bronchial wall needs to be included. In the bronchial adenoma group, the cylindro-
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matous variety is not amenable to this form of treatment because of the tendency of the tumors to extend several inches along the bronchi and cross the carina into the opposite main bronchus. Although bronchiectasis may be present if the lung aerates, it probably will be asymptomatic and serial bronchographic studies postoperatively may show a diminution in the caliber of the previously dilated bronchi. Transpleural bronchotomy is a method for conserving pulmonary function and lung while at the same time curing the patient of the tumor. Follow-up studies of carcinoid adenoma treated in this way have shown no evidence of recurrence for periods up to 13 years. The prognosis in carcinoid adenoma and in fibromas, lipomas and hamartomas is excellent. Pleural Tumors Attached to the Visceral Portion of the Lung. These tumors reach a large size without showing evidence of metastases if they are, histologically, fibroma or fibrosarcoma of low grade malignancy. They are thus amenable to local excision with only a small part of the attached lung. Carcinoma and Other Malignant Tumors of the Lung
Carcinoma of the lung is now a most important surgical disease of the lung. It has apparently increased approximately twentyfold in the last 20 years. Exposure of large segments of the total population of Occidental nations, such as Britain, France and the United States, to chemical irritants, potentially carcinogenic, is believed to be responsible for this increased incidence. Smog, gasoline fumes, industrial fumes, industrial chemicals such as chromate and berryllium, and tobacco smoke have been incriminated. The most effective treatment is surgical removal. The disease has been primarily a disease of males but there is an apparent increase in the female. It is essentially a disease of the middle-aged and aged but increasing instances occur in the third and fourth decades. Approximately 25 per cent of patients treated by resection have a fiveyear survival. COMMENT
Advances in the indications, diagnosis, and preoperative and postoperative care of a few important surgical diseases of the lungs have been discussed. Many -more such diseases exist (Table 1 and Figs. 171, 172 and 173); in fact, today's surgical diseases of the lung have no hard and fast boundary. Almost every patient with a significant pulmonary disease may require surgical consideration. A large proportion of today's pulmonary surgery is done simply for diagnosis, as, for example, lung biopsy in pulmonary hypertension associated with heart disease or Rich-Hamman's fibrosis of the lung. Medical treatments such as steroid therapy usually require such accurate histological diagnosis. Tracheotomy, tracheal suction, antibiotic therapy and chemotherapy
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Fig. 171. Bullous emphysema. X-ray film of the chest showing catheter in right ventricle for cardiac catheterization and pulmonary angiography. Note the large bullae occupying the upper two-thirds of the right lung. Angiogram demonstrates that the circulation of the pulmonary artery of the lower and compressed portions of the right lung is adequate.
Fig. 172. Same case as Figure 171. Surgical specimen showing resected bullae.
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Fig. 173. Same case as Figures 171 and 172. Photograph taken at operation showing suture line through the base of the bullae used to approximate "cotton candy" lung of such emphysematous patients.
have extended the safety of thoracic surgery. Newer bronchoplastic procedures have made possible better conservation of pulmonary function. More accurate roentgenologic interpretation, greater attention to physiological factors, improvements in anesthesia and the over-all increase of experience in the management and techniques of surgery ,have made it possible to obtain satisfactory results from extended thoracic surgical procedures. At present thoracic surgery is a rapidly growing and dynamically changing area of surgery and its future holds still greater promise as indications undergo further clarification and new or improved techniques are developed. REFERENCES 1. Auerbach, 0.: Tuberculosis as Affected by Antibiotics. In: Bronchopulmonary Disease, New York, Paul B. Hoeber, 1957, pp. 536-545. 2. Brunn, H., Shipman, S., Goldman, A. and Ackerman, I.J. : Tuberculous Cavitation and Transpleural Decompression, J. Thoracic Surge 10: 485-500, 1941. 3.. Chamberlain, J. IVI. :.Segmental Resection. In: Bronchopulmonary Diseases, New York, Paul B. Hoeber, 1957, pp. 582-590. 4. Churchill, E. D. and Belsey, R.: Segmental Pneumonectomy in Bronchiectasis. Ann. Surge 109: 481, 1959. 5. Cotton, B. H., Paulsen, G. A. and Birsner, J. W.: Surgical Considerations in Coccidioidomycosis. In: Bronchopulmonary Disease, New York, Paul B. Hoeber, 1957, pp. 417-422. 6. Davis, E., Peabody, J. and Katz, S.: The Solitary Pulmonary Nodule-A TenYear Survey Based on 215 Cases. J. Thoracic Surge 32: 728, 1956. 7. d'Abreu, A. L.: A Practice of Thoracic Surgery. London, Edward Arnold & Co., 1953.
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8. Goldman, A. and others: Segmental Resection for Pulmonary Tuberculosis. Am. Rev. Tuberc. 70: 285-295, 1954. 9. Goldman, A.: The 1V[alignant Nature of Bronchial Adenoma. J. Thoracic Surge 18: 137-148, 1949. 10. Goldman, A.: Transpleural Bronchotomy. J. Thoracic Surge 23: 237-250, 1952. 11. Jackson, C. L. and Huber,J. F.: Correlated Applied Anatomy of Bronchial Tree and Lungs with a System of Nomenclature. Dis. Chest 9: 1-8,1943. 12. Johnson, J. and Kirby, C. K.: Surgery of Chest. Chicago, Year Book Publishers, 1952. 13. Moersch, H. J., Tinney, W. S. and McDonald, J. R.: Adenoma of Bronchus. Surg., Gynec. & Obst. 81: 537-558, 1945. 14. Monaldi, V.: L'aspirazione endocavitaria nella cura delle caverne tubercolari del polmone. Settimana med. sper. 8: 3, 1939. 15. Overholt, R. H., Langer, L., Szypulski, J. T. and Wilson, N. J.; Pulmonary Resection in Treatment of Tuberculosis; Present-Day Techniques and Results. J. Thoracic Surge 15: 384-413, 1946. 16. Rigler, I.J. G.: Roentgen Study of Evolution of Carcinoma of Lung, J. Thoracic Surge 34:283-297,1957. 17. Schwartz, W. S. and Moyer, R. E.: Pyrazinamide and Cycloserine in Treatment of Pulmonary Tuberculosis. Am. Rev. Tuberc. 76: 1097, 1957. 18. Semb, C.: Thoracoplasty with Extrafascial Apicolysis. Acta. chir. Scandinav. 76 (Suppl. 37): 1, 1935. 19. Som, M. L.: Adenoma of Bronchus. Endoscopic Treatment in Selected Cases. J. Thoracic Surge 18: 462-473, 1949. 20. Sweet, R. H.: Lobectomy and Pneumonectomy in Treatment of Pulmonary Tuberculosis. J. Thoracic Surge 15: 373-383, 1946. 21. Sweet, R. H.: Thoracic Surgery. Philadelphia, W. B. Saunders Co., 1950. 22. Trimble, H. G.: "Coin" Lesions-Medical and Pathologic Aspects. In: Bronchopulmonary Diseases, New York, Paul B. Hoeber, 1957, pp. 783--791. 416 N. Bedford Drive Beverly Hills, California
IN THE broad spectrum of pulmonary diseases, thoracic surgery is a diagnostic and therapeutic tool to be utilized in selected cases (Table 1). It follows that any given lesion of the lung may require a surgical procedure during the course of medical management. Such a concept implies close collaboration and consultation not only between the physician and surgeon but also with the ancillary specialists, particularly endoscopist, pathologist, otolaryngologist, bacteriologist and radiologist. Fortunately, only a small percentage of cases are true emergencies (i.e., thoracic injuries) so there is time to accumulate clinical data for complete evaluation of the patient in reference to the indications for surgical treatment as well as the type of operation to be performed. Nevertheless, the factor of timing surgical intervention should be given serious consideration lest either undue haste or delay mitigate against the best possible results. PULMONARY TUBERCULOSIS
In general, the incidence of patients requiring surgical treatment has decreased since the widespread use of effective chemotherapy during the past decade. It is well to keep in mind that chemotherapy! has made possible the safe introduction of resectional therapy15, 20 and that it is too early to be certain whether the recent trend toward less surgery in pulmonary tuberculosis will continue. Already large numbers of patients with sputums rendered negative by chemotherapy alone are returning after a period of months with positive sputums. 17 Many of these are now being considered for surgical help. PullIlonary Resection
Modern surgical treatment of pulmonary tuberculosis utilizes pulmonary resection as its major tool. This has evolved because pulmonary From the Thoracic Surgical Services, Cedars of Lebanon Ilospital, LotJ Angeles, California, and City of Hope Medical Center, Duarte, Californ'£a.
* Senior Attending Surgeon, Cedars of Lebanon Hospital; Co-Chairman, Department of Surgery and Surgeon-in-Chief, Thorac'£c and Cardiac Surgery, City of Hope Medical Center. 1055
Alfred Goldman
1056 Table 1 SURGICAL DISEASES OF THE LUNG
1. Tuberculosis a. Cavities b. Bronchostenosis c. Bronchiectasis d. Failure of collapse therapy e. Lower lobe disease f. Persistent positive sputum g. Destroyed lung h. Tuberculoma i. Bronchopleural cutaneous fistula j. Empyema k. Chondritis and osteomylitis of ribs and sternum 1. Hemoptysis 2. Primary neoplasms a. Benign b. Potentially malignant c. Malignant d. Metastatic 3. Fungus disease a. Coccidioidomycosis b. Blastomycosis c. Histoplasmosis d. Aspergillosis c. Nocardiosis f. Cryptococcosis 4-. Traumatic injury a. Continued bleeding b. Hemothorax (clotted) c. Captive lung d. Bronchial, tracheal, or vascular laceration e. Subcutaneous emphysema f. Tension pneumothorax 5. N ontuberculous suppurations a. Gangrene b. Bronchiectasis c. Lung abscess d. Mucoid bronchial impaction e. Lipoid pneumonia f. Foreign body, bronchus g. Bronchial obstruction with endobronchial disease and lymph node compression (middle lobe syndrome) 6. Coin lesions (of the lung) 7. Vascular lesions a. Aberrant systemic artery of the lung with sequestration b. Aneurysm c. Arteriovenous fistula d. Hemangioma 8. Pulmonary cysts a. Congenital b. Acquired (1) Cystic bronchiectasis (2) Epithelized cavities (3) Pneumocele (4) Bullae (5) "Disappearing" lung (6) Cysts associated with neoplasms (7) Parasitic cysts (hydatid)
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resection removes the lesion, does not result in deformity of the chest wall, is selective, does not unduly decrease pulmonary function, and results in more permanent conversion of the sputum. 8 Clinical indications are: 1. Cavities a. Thick-walled cavities b. Large or giant cavities c. Tension cavities d. Hemorrhaging cavities c. Lower lobe cavities 2. Bronchostenosis 3. Tuberculoma 4. Destroyed lung or lobe 5. Thoracoplasty failure 6. Bronchiectasis 7. Residual localized disease after prolonged chemotherapy
1:'he types of resectional therapy consist of subsegmentectomy, segmentectomy, lobectomy, pneumonectomy and pleural penumonectomy.5. 7,21 SUBSEGMENTECTOMY
Subsegmentectomy is indicated when the lesion is small, usually less than 4 cm., and located subpleurally. This procedure is most often employed as an adjunct to resection of a larger portion of the lung. It should be remembered that tuberculosis of the lung is usually bilateral but not often active bilaterally and that minor nodular disease may safely be left after resection of the active disease. SEGMENTECTOMY
Modern surgical treatment of tuberculosis utilizes mainly segmental resection and lobectomy in its attack on the disease. The size of the necrotic lesion, its location, and the absence of extensive exudative or caseous pneumonic disease as well as the duration of the lesion are important considerations in the indications for segmentectomy. Chamberlain3 has summarized the indications as follows: "The ideal indication for segmental resection is the fibrocaseous lesion with or without a cavity and devoid of an exudative element. The focus should be of such size and duration that mature medical opinion is doubtful of the patient's future security." Preparation of the Patient. Localization of the lesion and determination of its size and character are best studied with the aid of body section radiography, especially lateral views. Preliminary tuberculous drug therapy is the sine qua non for success in this operation because morbidity and mortality are reduced by preparation of the patient. Generally speaking, "triple treatment" consisting of streptomycin, 1 gram three times weekly, intramuscularly, para-aminosalicylic acid, 12 grams
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Alfred Goldman
daily, and isonicotinic acid hydrazide, 300 to 1000 mg. daily are given preoperatively for months or years until the tubercle bacilli in the sputum or gastric secretions can either no longer be detected or appear very rarely in monthly examinations. Prolonged chemotherapy in the face of resistant organisms is to be avoided. The patient with resistant tubercle bacilli should be studied for sensitivity to viomycin (dosage 2 to 3 grams twice weekly, intramuscularly) oxytetracycline (dosage 2 grams daily), pyrazinamide (dosage 3 grams daily), and kanamycin (dosage 0.5 gram four times daily, intramuscularly). Since these latter drugs may have specific toxicity, thorough knowledge of their toxic effects is a prerequisite to their use. Less toxic is Dipasic (Panray), 10 mg. per kilogram of body weight. Postoperative Management. Postoperatively the chemotherapy is continued for months or years until in the judgment of the physician it is safe to stop the treatment. The time for discontinuing chemotherapy is based upon experience plus an evaluation of the clinical status of the patient particularly through bacteriological examination of sputa and gastric secretions, x-ray films of the chest, and the elimination of toxicity, cough and expectoration. A period of observation with ambulation and work is often necessary. M orbidity, Mortality and Results. Mortality from this operation should not exceed 3 to 5 per cent and good results with conversion of sputum can be expected in 90 to 95 per cent of selected patients. Morbidity consists of bronchopleural fistula (approximately 10 per cent), empyema (approximately 5 per cent) and spread of disease (approximately 3 per cent). The bronchopleural fistulas are generally small and readily controlled in the majority of instances through closed or open drainage of the pleural cavity plus tailoring thoracoplasty as indicated. Rarely, lobectomy may be required. For encapsulated tuberculous empyema with bronchopleural fistula, we prefer drainage by the Eloesser skin flap technique. Spreads are most often amenable to continued chemotherapy plus prolonged bed rest. In such instances, larger doses of isonicotinic acid hydrazide, up to 1000 mg. daily, may be effective. LOBECTOMY
I ndications are: Large or giant cavities Lobar bronchostenosis Segrpental resection failures Thoracoplasty failures when the remaining lobes are so little affected as to be safe to leave 5. Tuberculous bronchiectasis with lobar localization 6. Uncontrolled lower lobe disease involving more than one segment
1. 2. 3. 4.
Lobectomy vs. Segmentectomy for Upper Lobe Disease. Since tuberculosis is primarily an upper lobe disease and because the right upper lobe is
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particularly amenable to resection without exposing fractured areas of leaking alveoli from the middle and lower lobes, whenever the disease is associated with two segments of the right upper lobe we prefer lobectomy to segmentectomy. In the left upper lobe because of the anatomical relationshipll of the posterior-apical segment, segmentectomy is frequently preferred to lobectomy. In this connection, it should be realized that the lingula4 has no fissure separating it from the left upper lobe so that there is no advantage in left upper lobectomy without lingulectomy from the standpoint of fracturing through the air sacs contiguous with the left upper lobe lingula. The morbidity associated with segmentectomy has influenced us to perform lobectomy rather than segmentectomy in certain borderline cases. Postoperative Care and Results. The postsurgical care of patients with lobectomy usually requires three to six months of bed rest and a total of six to nine months for further rehabilitation. When the open lesion has been removed by lobectomy, sputum conversion of 90 to 95 per cent can be expected. PNEUMONECTOMY
Pneumonectomy is rarely indicated today since the majority of patients are discovered at an earlier stage of their disease. In bilateral disease, pneumonectomy is still less frequently indicated. The major indication is a destroyed lung and, secondly, when the stem bronchus is markedly stenotic. The contralateral lung should be free of disease or disease should be minimal. Pulmonary function should be adequate to maintain life and not result in the production of a respiratory cripple. Mortality from pneumonectomy is approximately 10 per cent. Tuberculous empyema is a very serious postoperative complication of pneumonectomy. Diminution of the pleural space on the resected side is desirable as a preventive measure and this may be accomplished by resection of the phrenic nerve during pneumonectomy. Tailoring by partial thoracoplasty may also be indicated. PLEURAL PNEUMONECTOMY
This operation is reserved for the treatment of tuberculous empyema with underlying destroyed lung. In those patients who have had prolonged pneumothorax treatment and whose lungs cannot be restored to function or expansion and the pleura is infected, pleural pneumonectomy may be indicated. The mortality is approximately 10 per cent and the end results are good to excellent in approximately 90 per cent of the remainder. Collapse Therapy Pneumothorax. Pneumothorax is rarely indicated in the modern management of pulmonary tuberculosis. The same may be said of pneumo-
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Alfred Goldman
peritoneum. In most centers these procedures are losing their vogue primarily because they require years of treatment and do not so often lead to complete conversion of sputum or complete rehabilitation of the patient as does resectional therapy. Loss of pulmonary function cannot be controlled because of the unpredictable behavior of the bronchial factor,2 and pleural complications from pneumothorax have a high incidence. Besides, the residual disease is always present since it is not removed. Pneumoperitoneum. Repeated fillings of air into the peritoneal cavity avoid pleural complications. Their widespread use is controversial. Staged Thoracoplasty. A lesser sputum conversion rate of approximately 70 per cent with a slow conversion, pain, predisposition to spread, and deformity of the chest wall plus the necessity for multiple operations have been largely responsible for the discontinuance of the standard staged posterior thoracoplasty. In some clinics, thoracoplasty plus extrafascial dissection after the technique of Semb 18 is still popular. Carefully staged thoracoplasty in the older age group, with chemotherapy, may be considered the safest and simplest procedure to control that particular patient's disease. Deformity and painful chest wall are the major deterrent factors. Plombage. As a collapse measure, plombage with the aid of many kinds of foreign materials, such as Ivalon sponge, Lucite spheres, and paraffin, placed either in the extrapleural or extrafascial space with preservation of the ribs, in some instances by partial subperiosteal dissection so as to prevent deformity, has been utilized as a substitute for staged thoracoplasty. The advantages over thoracoplasty are: operation is done in one stage, and deformity of the chest wall is eliminated. In those centers not set up for pulmonary resection, plombage procedures are indicated particularly for young women of marital age in whom deformity of the chest wall is highly objectionable. '"fhe disadvantages are the use of a foreign material which may be associated with infection in future years, and the fact that pulmonary resection if required later is more difficult and the permanent conversion rate of the sputum is lower than is obtained by resection. Large cavities are not amenable to this type of collapse therapy both because the closure rate is relatively low and the complications of rupture of the cavity with infection of the plombage space are relatively high. CavernostOInY and Drainage of Cavity
The Monaldil4 technique for drainage of cavities requires meticulous care. Morbidity as regards pleural infection, chest wall sinuses, and failure of closure of the cavity is so frequent and the general drainage period so prolonged for months or years as to be a major deterrent in favor of other closed procedures when they will accomplish satisfactory results. In patients with giant cavities, external drainage of the cavity
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either by the Monaldi technique or open drainage of the cavity with removal of a portion of rib and roof of the cavity with insertion of a skin flap are indicated when no other method appears to be effective. Such drainages frequently require many months or years of daily dressings as well as secondary procedures such as application of pectoral muscle flaps inserted into the residual draining lung cavity in order to produce final closure of the chest wall. Decortication of the Lung
Indications are: 1. Nonexpansion of the lung following artificial pneumothorax 2. To aid in re-expanding residual lung during pulmonary resection 3. Encapsulated empyema associated with underlying lung not requiring resection or collapse 4. Captive lung associated with obliteration of a pneumothorax space by mediastinal and cardiac shift rather than by pulmonary re-expansion
N onexpansion of the Lung Following Artificial Pneumothorax. In general, decortication should not be employed for expanding any lung in which the tuberculous process may be reasonably expected to become active or is active at the time. In assessing the patient for decortication, he should be studied bronchoscopically for the presence or absence of significant bronchostenosis since bronchostenosis interferes with reexpansion of the lung. Pulmonary function may be studied by physiological testing and pulmonary circulation by angiography to make certain that chronic emphysematous changes have not occurred to such an extent that they will produce major symptoms and reactivation of tuberculosis after the lung is brought to re-expansion. In the immediate postoperative period, maintenance of a clean bronchial airway and suction in the pleural cavity to produce quick and permanent re-expansion of the lung are necessary features for success of the operation. Decortication During Pulmonary Resection; "Pleural Weaving." In many instances, chronic minimal pleural involvement is seen when the chest is opened for pulmonary resection. Over the lower lobes there is frequently found a delicate warp and woof of pleural adhesions which can be teased from the normal visceral pleura. When this separation has been completed, captive lung which had been folded in on itself reexpands under the influence of "bagging" by the anesthetist. The removal of this delicate pleural weaving is tedious and constitutes a decortication somewhat different from removal of visceral peel but is nonetheless necessary for success of the pulmonary resection. Encapsulated Empyema. The peel encompassing such encapsulated empyemas may be 1 or 2 cm. thick and involves not only the visceral but the parietal pleura. It may also be expedient to leave behind the parietal peel. Should the lung not expand satisfactorily during the post-
Alfred Goldman
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operative period, selective thoracoplasty is useful to obliterate the pleural space. Captive Lung Without Pleural Empyemas or Pockets of Air. The indication for removal of the thick pleural peel in these patients is to relieve them of the symptoms from torsion of the heart and great vessels, such as tachycardia, dyspnea, thoracic discomfort, and pain. COCCIDIOIDOMYCOSIS
Coccidioidomycosis is on the increase, apparently as the result of movements of population, establishment of air fields in endemic areas and the heavy automobile and truck movements particularly in farming areas where the organism inhabits the soil. It appears to be spread in the dusts from the soil. The disease mimics tuberculosis in practically all its forms. Cotton6 cites the following indications for operation: 1. 2. 3. 4.
Giant cavity Secondarily infected cavities Check valve cavity Ruptured cavity (pleural effusion, spontaneous pneumothorax, cmpyenul, bronchopleural fistula, nonexpansion of lung) 5. Coccidioidomycoma 6. Continued and severe hemoptysis
Coccidioidal Cavities. It is not necessary to operate on the thin-walled, asymptomatic cavity of small or moderate size because the disease does not have the public health aspects of tuberculosis; and, since dissemination occurs in only one of 400 cases of infection with coccidioides of all types, the patient harboring such a cavity is in little danger. Giant cavities, larger than 5 cm., should be operated upon because of the danger of rupture and empyema and the high incidence of hemoptysis and secondary infection. Infected cavities, check valve cavities, and bleeding cavities produce toxicity and serious symptomatology which is rarely relieved except by resection. Ruptured cavities produce spontaneous pneumothorax, empyema, bronchopleural fistula and nonexpansile lung and so require relief of the collapse of the lung and drainage of the pleural space with decortication and closure of the bronchopleural fistula or resection of the cavity, as with tuberculosis. Preparation of Patients with Coccidioidomycosis for Operation. The acute phase of the disease should have passed. This generally takes approximately six months. Chemotherapy as for tuberculosis is not necessary but the ascertainment of bronchiectasis and localization of the cavity by endoscopic and radiological procedues is necessary. The general condition of the patient should be improved so that he can stand localized resection or lobectomy, as the case may be. Postoperatively the dissemination is negligible. A prolonged period of rehabilitation is not required. Early ambulation and return to work in approximately one month after uncomplicated surgical procedures are to be expected.
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COIN LESIONS OF THE LUNG
During the past ten years, it has become appreciated especially as a result of x-ray surveys in the military services and mass x-ray surveys for pulmonary tuberculosis that a relatively high number of lesions of varying sizes can be visualized in the asymptomatic stage. Approximately 3000 such lesions were discovered in the Los Angeles mass survey of 1,700,000 x-ray films. Such patients should be considered tumor suspects until proved otherwise. These lesions may present as round, so-called coin lesions, localized infiltrations in varying degrees of bronchial obstruction with atelectasis. A long list of diseases, of which mass survey lesions are a manifestation, has been reported by many observers. They include chronic abscesses, granuloma of unknown etiology, specific granulomas, tuberculoma, coccidioidomycoma, histoplasmoma, hydatid disease, pulmonary infarction, nonspecific pneumonitis, arteriovenous fistula of the lung, bronchial adenoma, fibroma, lipoma, hamartoma, pleural mesiothelioma, sarcoma and carcinoma (both primary and metastatic). According to Trimble,22 the major problem is not so much an exact diagnosis but the immediate and pressing question of whether or not this x-ray shadow represents carcinoma. Rigler16 has pointed out that carcinoma has an asymptomatic stage when it appears as a coin lesion in the x-ray. Characteristically, the "coin lesion" that is malignant may have a notch at its periphery. Such lesions are rarely calcified. A search should be made for all previous x-rays of the chest which the patient has had. A film one year old that is negative, especially that of a male over the age of 40 who is presently being investigated for a coin lesion, is highly indicative that the lesion is a new growth and probably carcinoma. Because pulmonary resection of such asymptomatic carcinomas has led to a higher five-year survival rate than in the ordinary run of surgical resections for carcinoma, it is important that definitive diagnosis be obtained before eliminating the prospect of carcinoma of the lung. This can usually be accomplished only by exploratory thoracotomy,6 albeit sputum examinations for tumor cells, fungi, and acid fast bacilli should be carried out. Bronchoscopy is especially indicated in patients with severe cough, as occasionally the "coin lesion" is a metastatic growth associated with a primary bronchogenic carcinoma invading the walls of the large bronchi. If the index of suspicion is low, bronchoscopy may be omitted, otherwise it is indicated in the preoperative studies. Other Diagnostic Procedures. It is rarely necessary to perform roentgenologic bone surveys, gastrointestinal x-ray series, or special investigations of the genitourinary tract in the patient with "coin lesion" because of the dearth of symptoms referable to these systems. Should symptoms be present, the special x-ray examinations indicated should be performed. Appropriate special laboratory examinations including those for tubercle bacilli, Bence-Jones protein in urine, tests for aglobulinemia such as the
1064
Alfred Goldman
electrophoretic pattern of the serum, skin tests for coccidioides, blastomycosis, undulant fever and tuberculosis, cytologic examination of the sputum, examinations of the esophageal and gastric contents, complement fixation and agglutinin tests of the serum, guinea pig inoculation and culture of the sputum may on occasion yield confirmatory evidence when there is a high index of suspicion from the history, physical examination and routine radiological and clinical laboratory work-up. Because of the scarcity of positive results, however, we advise in general that the preoperative diagnostic work-up in those lesions with a high index of suspicion of neoplasm should include only (1) examination of the sputum for malignant cells and (2) skin tests for coccidioides, tuberculosis and histoplasmosis. A prolonged search by laboratory aids for a specific diagnosis is apt to lead to confusion and important loss of time which may mitigate against the benefits to be achieved by early exploratory thoracotomy. Exploratory Thoracotomy. In the noncalcific lesion, exploratory thoracotomy is indicated in all instances in which the general condition of the patient is not a contraindication and the suspicion of neoplasm exists. This operation has an extremely low morbidity and mortality rate, in the neighborhood of 1 per cent or less, and results in a positive diagnosis in almost all cases. A pathologist should always be present and available to make a frozen section diagnosis as well as diagnosis from the gross specimen submitted to him. The definitive surgical therapeutic procedure can then be carried out without the patient having to undergo a separate procedure. Significance of the Presence of Calcium. Some "coin lesions" contain radiopaque material and are usually called "calcific," thus indicating the higher probability of granuloma. Certain adenomas, particularly those of the mixed tumor variety, may develop osteoid tissue and even bone formation, carcinoma of the lung may arise in close proximity to old calcific foci of the lung, but the great majority of calcific lesions are granulomas and a high index of suspicion of this diagnosis may be achieved from the roentgenological study. The "coin lesion" should generally not be watched, but exceptions to this rule may be made if calcium is present, and the calcified lesion should be removed if it shows any sign of enlargement or if in the opinion of experienced observers the lesion is highly suggestive of neoplasm. The reason for this emphasis on the importance of exploratory thoracotomy for !'coin lesion" is based upon the finding in large series of patients so explored that approximately one-third of the lesions found were malignant. Patients are frequently referred to thoracic surgical clinics whose original x-rays one or two years before showed a "coin lesion" but whose present x-rays show a large inoperable cancer of the lung. This is truly a sad experience and warrants the dictum, !!coin lesions should not be watched."
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TUMORS OF THE LUNG
Benign and Potentially Malignant Lesions of the Lung
The benign lesions of the lung are fibroma, lipoma, hamartoma, myo.. blastoma and inflammatory polyps. The potentially malignant lesions, if not in fact actually malignant from the start of their growth, are primarily the bronchial adenomas. 9 The most important therapy for all these tumors is surgical excision, which may be accomplished by endoscopy, transpleural bronchotomy, ID or pulmonary resection, i.e., segmentectomy, pneumonectomy or lobectomy. While serious symptoms from bronchial obstruction and hemoptysis are associated with benign pulmonary tumors, the prognosis is excellent. Endoscopic Treatment. Tumors that arise in the stem, lobar or segmental bronchi may sometimes be removed through the bronchoscope provided they have a thin stalk or pedicle and lie relatively free in the lumen of the bronchus. All such accessible tumors should have a bronchoscopic biopsy. In many instances relief of bronchial obstruction can be obtained through aspiration of the dammed-up secretions distal to the obstructing tumor. Endoscopy, therefore, may be valuable in the preparation of the patient as well as in diagnosis. 13 • 19 However, 90 per cent of these tumors cannot be removed totally via the bronchoscope because of intramural or extramural extension of the tumor. Transpleural Bronchotomy. Benign tumors arising in the stem, lobar or segmental bronchi are especially amenable to local excision by transpleural bronchotomy. This procedure enables a thorough exploration of the pleural cavity and mediastinum for evidence of metastases and of irreversible lung destruction that may be caused by prolonged bronchial obstruction. Bronchography may demonstrate bronchiectasis distal to the tumor. Characteristically, the lung that has been obstructed has its bronchial tree full of dammed-up bronchial secretions which may be either purulent or mucoid. In some instances, the obstructed lung has been converted to a cystic bag. TECHNIQUE OF TRANSPLEURAL BRONCHOTOMY. ID After the chest is entered, the bronchus containing the tumor is thoroughly inspected in its outer aspect for evidence of extrabronchial portions of the tumor and involved lymph nodes. Biopsy material for frozen section may be obtained at this time. Guide sutures are placed in the bronchial wall, after which the bronchus is incised in the noninvolved area and the incision developed to delineate the characteristics of the surface of the tumor and its attachment at the bronchial wall. The tumor is then excised with the bronchial wall and the bronchus closed with interrupted silk sutures by a plastic technique which leaves an adequately ventilating lumen of the bronchus. In some instances, sleeve resection of the entire wall of the bronchus is necessary and in others only a portion of the bronchial wall needs to be included. In the bronchial adenoma group, the cylindro-
Alfred Goldman
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matous variety is not amenable to this form of treatment because of the tendency of the tumors to extend several inches along the bronchi and cross the carina into the opposite main bronchus. Although bronchiectasis may be present if the lung aerates, it probably will be asymptomatic and serial bronchographic studies postoperatively may show a diminution in the caliber of the previously dilated bronchi. Transpleural bronchotomy is a method for conserving pulmonary function and lung while at the same time curing the patient of the tumor. Follow-up studies of carcinoid adenoma treated in this way have shown no evidence of recurrence for periods up to 13 years. The prognosis in carcinoid adenoma and in fibromas, lipomas and hamartomas is excellent. Pleural Tumors Attached to the Visceral Portion of the Lung. These tumors reach a large size without showing evidence of metastases if they are, histologically, fibroma or fibrosarcoma of low grade malignancy. They are thus amenable to local excision with only a small part of the attached lung. Carcinoma and Other Malignant Tumors of the Lung
Carcinoma of the lung is now a most important surgical disease of the lung. It has apparently increased approximately twentyfold in the last 20 years. Exposure of large segments of the total population of Occidental nations, such as Britain, France and the United States, to chemical irritants, potentially carcinogenic, is believed to be responsible for this increased incidence. Smog, gasoline fumes, industrial fumes, industrial chemicals such as chromate and berryllium, and tobacco smoke have been incriminated. The most effective treatment is surgical removal. The disease has been primarily a disease of males but there is an apparent increase in the female. It is essentially a disease of the middle-aged and aged but increasing instances occur in the third and fourth decades. Approximately 25 per cent of patients treated by resection have a fiveyear survival. COMMENT
Advances in the indications, diagnosis, and preoperative and postoperative care of a few important surgical diseases of the lungs have been discussed. Many -more such diseases exist (Table 1 and Figs. 171, 172 and 173); in fact, today's surgical diseases of the lung have no hard and fast boundary. Almost every patient with a significant pulmonary disease may require surgical consideration. A large proportion of today's pulmonary surgery is done simply for diagnosis, as, for example, lung biopsy in pulmonary hypertension associated with heart disease or Rich-Hamman's fibrosis of the lung. Medical treatments such as steroid therapy usually require such accurate histological diagnosis. Tracheotomy, tracheal suction, antibiotic therapy and chemotherapy
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Fig. 171. Bullous emphysema. X-ray film of the chest showing catheter in right ventricle for cardiac catheterization and pulmonary angiography. Note the large bullae occupying the upper two-thirds of the right lung. Angiogram demonstrates that the circulation of the pulmonary artery of the lower and compressed portions of the right lung is adequate.
Fig. 172. Same case as Figure 171. Surgical specimen showing resected bullae.
Alfred Goldman
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Fig. 173. Same case as Figures 171 and 172. Photograph taken at operation showing suture line through the base of the bullae used to approximate "cotton candy" lung of such emphysematous patients.
have extended the safety of thoracic surgery. Newer bronchoplastic procedures have made possible better conservation of pulmonary function. More accurate roentgenologic interpretation, greater attention to physiological factors, improvements in anesthesia and the over-all increase of experience in the management and techniques of surgery ,have made it possible to obtain satisfactory results from extended thoracic surgical procedures. At present thoracic surgery is a rapidly growing and dynamically changing area of surgery and its future holds still greater promise as indications undergo further clarification and new or improved techniques are developed. REFERENCES 1. Auerbach, 0.: Tuberculosis as Affected by Antibiotics. In: Bronchopulmonary Disease, New York, Paul B. Hoeber, 1957, pp. 536-545. 2. Brunn, H., Shipman, S., Goldman, A. and Ackerman, I.J. : Tuberculous Cavitation and Transpleural Decompression, J. Thoracic Surge 10: 485-500, 1941. 3.. Chamberlain, J. IVI. :.Segmental Resection. In: Bronchopulmonary Diseases, New York, Paul B. Hoeber, 1957, pp. 582-590. 4. Churchill, E. D. and Belsey, R.: Segmental Pneumonectomy in Bronchiectasis. Ann. Surge 109: 481, 1959. 5. Cotton, B. H., Paulsen, G. A. and Birsner, J. W.: Surgical Considerations in Coccidioidomycosis. In: Bronchopulmonary Disease, New York, Paul B. Hoeber, 1957, pp. 417-422. 6. Davis, E., Peabody, J. and Katz, S.: The Solitary Pulmonary Nodule-A TenYear Survey Based on 215 Cases. J. Thoracic Surge 32: 728, 1956. 7. d'Abreu, A. L.: A Practice of Thoracic Surgery. London, Edward Arnold & Co., 1953.
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8. Goldman, A. and others: Segmental Resection for Pulmonary Tuberculosis. Am. Rev. Tuberc. 70: 285-295, 1954. 9. Goldman, A.: The 1V[alignant Nature of Bronchial Adenoma. J. Thoracic Surge 18: 137-148, 1949. 10. Goldman, A.: Transpleural Bronchotomy. J. Thoracic Surge 23: 237-250, 1952. 11. Jackson, C. L. and Huber,J. F.: Correlated Applied Anatomy of Bronchial Tree and Lungs with a System of Nomenclature. Dis. Chest 9: 1-8,1943. 12. Johnson, J. and Kirby, C. K.: Surgery of Chest. Chicago, Year Book Publishers, 1952. 13. Moersch, H. J., Tinney, W. S. and McDonald, J. R.: Adenoma of Bronchus. Surg., Gynec. & Obst. 81: 537-558, 1945. 14. Monaldi, V.: L'aspirazione endocavitaria nella cura delle caverne tubercolari del polmone. Settimana med. sper. 8: 3, 1939. 15. Overholt, R. H., Langer, L., Szypulski, J. T. and Wilson, N. J.; Pulmonary Resection in Treatment of Tuberculosis; Present-Day Techniques and Results. J. Thoracic Surge 15: 384-413, 1946. 16. Rigler, I.J. G.: Roentgen Study of Evolution of Carcinoma of Lung, J. Thoracic Surge 34:283-297,1957. 17. Schwartz, W. S. and Moyer, R. E.: Pyrazinamide and Cycloserine in Treatment of Pulmonary Tuberculosis. Am. Rev. Tuberc. 76: 1097, 1957. 18. Semb, C.: Thoracoplasty with Extrafascial Apicolysis. Acta. chir. Scandinav. 76 (Suppl. 37): 1, 1935. 19. Som, M. L.: Adenoma of Bronchus. Endoscopic Treatment in Selected Cases. J. Thoracic Surge 18: 462-473, 1949. 20. Sweet, R. H.: Lobectomy and Pneumonectomy in Treatment of Pulmonary Tuberculosis. J. Thoracic Surge 15: 373-383, 1946. 21. Sweet, R. H.: Thoracic Surgery. Philadelphia, W. B. Saunders Co., 1950. 22. Trimble, H. G.: "Coin" Lesions-Medical and Pathologic Aspects. In: Bronchopulmonary Diseases, New York, Paul B. Hoeber, 1957, pp. 783--791. 416 N. Bedford Drive Beverly Hills, California